**All applications are subject to approval by The Prince Synergy.
APPLICATION FOR ADMISSION
Your Training/Consulting: ____________________________ (Training/Consulting)
Location: Date: Fee:
GENERAL INFORMATION:
Name: _____________________________________________________________
Last (family) First Middle Initial Prefix(Mr., Ms.) Suffix(Jr., II)
Your Company Name: Your title:
Business Address:
__________________________________________________________________
Street City State/Country Zip Code/Postal code
City/Country of Birth: Date of Birth:
Your Home Address:
__________________________________________________________________
Street City State/Country Zip Code/Postal code
Telephone (the easiest to reach you and the second):
Cell: Work: Home:
E-mail address:
Preferred Mailing Address: ___ Business Address ___ Home Address
LANGUAGE: Proficiency in spoken English is essential for active participation in classes
and discussions.
SOME QUESTIONS:
1. Please explain your goals and objectives as they relate to attending this program.
2. What are the most formidable challenges that you or your group are facing? What
might be the reason(s)?
3. What do you anticipate to be in the next five years?
PAYMENT:
The Prince Synergy accepts corporate checks, major credit cards, Paypal, cashier
checks, Money Orders and persona checks (US funds only). Please make your
fund payable to The Prince Synergy. You may send your payment by fax or by
mail. Please fill out following if you use credit card.
Credit Card:___Visa ___Master ___American Express ___Discover ___(Other)
Card Number:_______________________ Expires:_______ CVV Code:________
Billing Address if different from Preferred Mailing Address:
___________________________________________________________________
Street City State/Country Zip Code/Postal code
______________________________
Your Signature
PLEASE RETURN THIS APPLICATION:
By Fax: By Mail:
The Prince Synergy The Prince Synergy
Fax:+1-310-820-2819 12304 Santa Monica Blvd., Suite 300
Los Angeles, CA 90025, U. S. A.
Disclaimer:
The Prince Synergy provides information for educational and informational purposes.
Its training and management consulting do not intend to substitute clinics or hospitals,
but assist you understand and utilize different resources in a more efficient way. Each
individual is so unique and complex that nobody in the study cases of The Prince
Synergy can fully represent.
Cancellation Policy:
Payment is due within 10 days of sign up. Cancellations or deferrals must be submitted
20 days prior to the start of the program for full refund. Due to program preparation and
schedule, cancellations or deferrals submitted within 20 days prior to the start of the
program are subject to a fee of one-third of program fee; within 7 days prior to the start
of the program are subject to two-thirds of program fee. No refund after the program
starts. If you would like to have someone attend the program in your place, we are happy
to make those changes without a fee as long as the person is suitable to the program. If
you have questions or need more information, please feel free to contact Judith at
+1-310-820-2829 or Judith@ThePrinceSynergy.com.