ADVANCED CERTIFICATION TRAINING
REGISTRATION FORM
Name: _____________________________________ Phone #: ___________________
Address: ___________________________________ City/State/Zip:____________
Course Name(s):____________________________________ Course Date:_____________________
Cost: __________ Payment Method: ( ) MO ( ) Master Card ( ) Visa ( ) Discover ( ) Check
Card Number #: _____________________________________ Exp. Date: __________
Signature: _____________________________________ Date: __________
Are you a NYIM Alumni Member? Yes _____ No _____
NYIM Student? Yes _____ No _____ EMAIL Address ______________________________________
Fill out the sign-up sheets and send back with your payment
to:
New York Institute Of Massage
P.O. Box 645
Buffalo, NY 14231
Register in person at NYIM or by phone if using a credit card. Make checks payable to NYIM.
A 50% nonrefundable deposit is required to hold a seat for each A.C.T. class. This deposit will be refunded if the class is cancelled. All classes are subject to cancellation without minimum enrollment requirements.
The remaining balance is due 30 days (one month) before the class is to take place.
If you have any questions or suggestions, please contact Joanne Herrmann at (716) 633-0355 ext. 230.