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| * First Name |
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| **Middle Initial |
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| * Last Name |
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| * Professional Degree |
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| * Address |
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| * City |
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| * State |
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| * Country |
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| * Zip |
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| * Phone |
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| * Fax |
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| * E-Mail |
(If you do not have an email please type in "None@thistime.com" ). |
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* Please Register Me for:
(Check all courses you wish to be enrolled in and then choose location) |
Module IV (Botulinum Toxin A & Facial Filler) $3500 |
| Please Select Location: |
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| Module V (Aesthetic Laser & Light) $2500 |
| Please Select Location |
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Module VI
(Chemical Peels, Sclerotherapy, Body
Contouring) $3500 |
| Please Select a Location |
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Module VII (Advanced Botox & Dermal Filler) $2500 |
| Please Select a Location |
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Module VII (Advanced Laser & Lights) $2500 |
| Please Select a Location |
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Module IX (Advanced Venous Treatments) $5000 |
| Please Select a Location |
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| Payment Terms: 50% due with registration. Balance due 14 days prior to event. An e-mail will be sent as a confirmation of your registration. Refunds will be given (less a $250 processing fee) until 30 days prior to the seminar. After 30 days, no refund will be issued; tuition may be transferred to a future course for an additional fee. |
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Please provide the information below: |
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| * Credit Card Type: |
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| * Credit Card Number: |
example: ( 1234567890123456 ) |
| * Expiration Date: |
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| * Enter Card Name: |
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| * Card Security Code: |
What is this? |
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Referred By:
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Accommodations for disabilities: Please notify The Ageless Aesthetic Institute at 800-420-2689a minimum of ten working days in advance of the event if a reasonable accommodation for a disability is needed.
The Ageless Aesthetic Institute reserves the right to cancel this activity due to unforeseen circumstances. In the event of such cancellation, the full enrollment fee will be returned to the registrant. USF will not be responsible for travel expenses incurred by the participant in the unlikely event that the program is cancelled.
Events, activities and facilities of USF are available without regard to race, color, sex, national origin, disability, age, or Vietnam veteran status as provided by law and in accordance with the University’s respect for personal dignity. |
