Registration Fee For

Original Divine Principle Workshop

Las Vegas, NV – June 4 - 8, 2009

CREDIT CARD AUTHORIZATION

HSA-UWC (FFWPU)
Please fill out, sign and submit to your State FFWPU Office
No later than 12:00 PM EDT, Thursday, May 28th, 2009

Name:_______________________________________
Date:_____________
(Write as it appears on your credit card)

Address:__________________________________________________________
_

City: ___________________________________ State:____ ZIP:

____________

Credit Card: VISA - MasterCard - Discover - AMEX

Registration Fee:
Double Occupancy $515.00
Single Occupancy $721.00

Please Charge My Card: $ 515.00 $ 721.00

Card Number:

Expiration Date:

Signature:

Telephone No:

Memo:
Paying For:

(If you are paying for someone else, please write the person’s name here)