ANIMAL ENCOUNTERS - 2005 / 2006

Directions: Print this form and fill it out (please print clearly). Mail your registration and payment to Hollywood Animals 4103 Holly Knoll Dr. Los Angeles CA 90027. Upon receipt of your registration, we will send you a package with all the information.

Encounter: No of Adults __________ No of Children __________

Occasion/Special Requests: ____________________________________________________________

Dates      First Choice___________ Second Choice____________

________________________	________________________
First Name	Last Name

Address _____________________________________________________________________________________________________

____________________________________________	_____________	__________
City	State	Zip

Home Tel_________________________

Work Tel __________________________

Cell/Pager _____________________________

Email ____________________________________________________________
DOB	_______________		Ca. DL	________________________________________

Payment	Course	Tuition & Fees
_____	ANIMAL ENCOUNTER	$495.00 per person	$ _______________
_____	ANIMAL ENCOUNTER	$900.00 per couple	$ _______________
_____	Hollywood Animals Personalize Gift Card	$15.00 / each	$ _______________
_____	Certificate of "Survival"	$27.00 / each	$ _______________
		Total	$ _______________

Minimum Deposit $ 150.00 / PP    Amount Enclosed $ _________
Payment:

Visa

________

MasterCard

________

Check

________

_____________________________________________________________
Name as it appears on credit card
___________________________________________	_______
Credit card number	Exp. Date

__________________________________	______________________
Billing Address	City
______________________	_________
State	Zip
____________________________
Home Tel:

I understand and agree to have my credit card charge for services/ products contracted with Hollywood Animals, Inc. I promise to pay subject to and in accordance with the agreement governing the use of such card.. I, the undersigned, certify under the penalty of perjury that the information on this application agreement is correct and I am over the age of 18 years old.

Signature of Credit Card Holder	Print name of credit card holder	Date

Names of others included in the encounter:	Age
_________________________________________________	___________
_________________________________________________	___________