Pure Care Wellness Workshop Booking Sheet
PO Box 494, Mt Hawthorn  WA  6916
Ph:  08 9443 5116     Email:  info@purecare.com.au
Please fill out the form below and post to Pure Care Wellness for workshop enrolment.
Name
Postal Address
Email
Phone				Mobile
Workshop Enrolling in:			Tick	Amount
Your Energy Body (Energy Medicine 101) - $330
Your Healing Centres & Self Healing Early Bird Rate Before 14/01/12 - $330
Your Healing Centres & Self Healing - $400
Both Workshops ($600 - save up to $130)
Total Amount
Payment Details	Tick
Cheque
Direct Transfer			Account Name:  Pure Care Company
			BSS:  036-044
			Account Number:  19-37-50
Credit			Card Number
			Card Name
			Security Code
			Expiry Date
			Address (address on statement of credit card used)
Authorising
By signing below I authorise Pure Care Wellness to deduct the amount of ____________________________
from my credit card details as given above.
Signature: