Name _____________________________________Companion Name______________________________

Address__________________________________________________________________________________

City__________________________________________State_______________Zip + 4__________________

Telephone _______________________________________Email____________________________________

I am: Male Female        I am: Non- Smoker Smoker I was Referred by_____________________________________

I want to register as the following: Double Occupancy with Non-Painting Companion $1,995.00 Double Occupancy, Please arrange a room mate. $1,395.00 Ea Single Occupany $1,895.00 Seminars & Meals (no sleeping arrangements) $850.00 Seminar Only $650.00 Meals and Non-painting Excursions $295.00         

   I prefer to room with the following person who is registered to attend this seminar.                           Name_____________________________________________________________________________________

Total Seminar Cost $______________                                                                                             

 A deposit of one-half of the total cost of the seminar is required to secure your spot. Cancellations up to April 30, 2009 will incur a $100.00 processing fee.

There will be no refunds after April 30, 2009.  Balance is due by April 30, 2009.

________________________________________________________________________________________________________

Method of Payment      Make Checks and/or Money Orders out to: Silver Falls Seminars

Visa Mastercard Check Money Order in US Currency   Amount to charge at this time $:____________________________________

Card#____________________________________________________________ Expires:__________________

3 digit security code on back of card _______ I authorized this fee to be charged to my credit card.

Signature X ________________________________________________________________________________

Directions: When Finished click edit, select all, copy.  Click on the email address below and paste into an email to Laurie Anderson. 

You may also print the form out and Mail to :

Silver Falls Painting Seminar, P.O. Box 699, Amboy, WA 98601

Please email Registration to arts.recreation@yahoo.com