RICK SMITH SEMINARS
Enrollment Form
Please enroll me in the following Rick Smith Foundation Seminar:
Fri, Sat & Sun, June 10-12, 2011
Whitehall, MT
   
_____________________________________________________
NAME (Print: as you would like it to appear on Diploma)
       
____________________________________________________________
Name (as you would like us to call you and for it to appear on name tag)

 
Address:___________________________________________________

___________________________________________________________
   
Phone #'s:__________________________________________________

E-Mail:____________________________________________________

Dog Breed:_______________________

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Tuition:    $400.00   (paid in advance to hold reservation)

Payment of  $__________  by:
   
a) Credit Card (circle one: Visa or MC)  Exp Date:______ Sec.Code: ______

Card Number: ______________________________

Signature: _________________________________
(If using credit card, we need name as shown on card and billing address, if different from above)

b) Check:
    Check #: __________ (Payable to Rick Smith - Do not send cash through the mail)

Mail completed enrollment form and payment to:   
Montana Brittany Club
Todd Breitenfeldt
P.O. Box 883
Whitehall, MT 59759

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