Accent Modification Center

 PH: (703) 757-5353              FAX: 803-43044

  REGISTRATION

 INTENSIVE COMMUNICATION SKILLS IMPROVEMENT PROGRAM

Last Name: __________________       First Name___________________

 Address:______________________________________________________

 State:    _____                                                              Zip: __________

DOB: ______________

Native Country:_________________      Native Language:______________

Years in US: ______________________

If your company is covering your program fees, please complete the following:

 Company Name:

Company Address:

Authorizing Name: 

Method of Payment:

                               Purchase Order (Fax to 803-442-3044)         

                   Check

                   Credit Card  (please add phone number for credit card holder)

 If you are covering your own expenses, please read the following: 

A non-refundable $100 deposit is due at time of registration.  All deposits will be returned in full if the class fails to register the required number (3) of students.