Name:________________________________________________

Address:______________________________________________

City ________________________State_____zip______________

School ___________________________zip__________________

e-mail________________________________________________

Phone #______________________________________________

Method of Payment______________________________________

Seminar location that you are planning to Attend:

______________________________________________________

Please check one PN Review ($250)______ RN Review ($300)______

Deposit enclosed:_______________________________________


DO NOT SEND CREDIT CARD INFORMATION BY E-MAIL


Credit Card #______________________________________


(indicate MasterCard, Visa, Discover)

MasterCard _______ Visa ________ Discover____________


Date of Expiration___________


Signature:_________________________________________


DO NOT SEND CREDIT CARD INFORMATION BY E-MAIL



Mail the form with your $50.00 deposit to:
Rinehart and Associates,
PO Box 124,
Booneville, MS, 38829.