| 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 |
| _________________________________________________ | ___________ |
| _________________________________________________ | ___________ |