Phone Consultation Registration Form

Please printout this registration form and complete the information by hand. PLEASE PRINT.

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Caroll Michels, Career Coach & Artist Advocate
1724 Burgos Drive • Sarasota, FL 34238
Phone: 941-922-5277 • Fax: 941-922-5278

I would like to arrange an initial phone consultation.

First Name Last Name

Address line1

Address line2

City State Zip Code or Postal Code

Country

Phone (include area code)

E-mail                                             Web site URL

The best day(s) of the week for a phone consultation are
Monday Tuesday Wednesday Thursday Friday
The best hours (Eastern Time) for a phone consultation are:
____________________________________________________
Enclosed is a check for $75.00 representing a deposit for an initial phone consultation
Please charge my $75.00 deposit for a phone consultation to my credit card:
American Express Mastercard Visa

Credit Card Number Expiration Date

Exact Name of Credit Card Holder

Exact Billing Address on Credit Card

Attention Artists Living Abroad:
If you are not charging the deposit to a credit card and do not have an American bank account, please use one of the following methods of payment:
Enclosed is a bank draft for $75.00 in U.S. dollars paid out to an American bank
for an initial phone consultation
Enclosed is an international money order or American Express money order
for $75.00 U.S. dollars for an initial phone consultation
Please note: Canadian postal orders are not accepted.

Privacy Notice:
Please be assured your name and personal information will never be rented, sold, or otherwise distributed to anyone, for any reason.