<p> REGISTRATION FORM Welcome to the Program!</p><p>Program Dates: Month, Days, Times • Cost of Program: $xxxx.xx Location: Building Address, 1234 Your Street, Your City, Your Zip</p><p>Total purchase: $______Total Down Payment: $______Total Amount Financed: $______</p><p> Visa  Discover  MasterCard  Check Check # ______</p><p>Credit Card Authorization:</p><p>Name as it appears on card (print):______</p><p>Card Number:______Exp. Date: ____ / ____ / ____ CSV ______</p><p>Home Phone: ( _____) ______Work Phone: ( _____) ______</p><p>Address:______</p><p>City:______State/Province:______Country: ______Zip/PC:______</p><p>Email: ______Fax: ( _____ ) ______</p><p>The Into Your Genius Program Includes:</p><p> 6 Teaching CDs, Workbook, Black Leather Zippered Binder</p><p> Instructor coaching for the duration of the program</p><p>Based on the groundbreaking findings in Napoleon Hill’s book, Think and Grow Rich, this program reveals six powerful mental faculties that, when applied to your life, minimize the struggle in goal achieving and create new and increasing levels of success.</p><p>Buyer’s Signature:______Date:______</p><p>Instructor: Consultant Name, Certified Life Mastery Consultant Contact Information • Email • Website</p>