PRE-REGISTER FORM

Please fill in the following pre-registration form. To order my online seminars, CDs or DVDs, click here.. By pre-registering for a live seminar, you will also receive a 10% discount with the purchase of any of my reinforcement DVDs.

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Country:
Phone Number:
Email Address:

YES, I want to see Jay at his seminar and receive a 10% discount on the purchase of his reinforcement program.

I will be attending the following program(s):

Weight Loss Program Stop Smoking Program Pain Management Program

at the following location:

Payment Method:
Visa
Master Card
Discover (Novus)
American Express
Money Order

Credit Card Number
Expiration Date

Comments:

I'll see you there!

Jay Block

Please make your check or money order out to Get HEALTHIER With HYPNOSIS and mail to:

Get HEALTHIER With HYPNOSIS
507 Mayberry Road, Rome, NY 13440

Fax orders should be sent to: (315) 337-6642

Main Page