PRE-REGISTER FORM

Please fill in the following pre-registration form. You can order my cassettes or go on-line for quicker access to my seminars click here. By pre-registering you will receive a 15% discount with the purchase of any of my live seminars & reinforcement cassettes.

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 15% discount on the purchase of his reinforcement program.

I will be attending the following program(s):

Weight Loss Program Stop Smoking Program

at the following location:

Payment will be: I will pay at the door

Payment Method:
Visa
Master Card
Discover (Novus)
American Express
Check or 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
TOLL FREE: 1-877-HYPNOSS

Fax orders should be sent to: (315) 337-9714

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