HOOPHOLE Mail and Fax Registration Form PRINT OUT THIS FORM Thank you for HAND PRINTING your responses! Date ___________________ First and Last Names ______________________________________________________ Street Address ___________________________________________________________ City, State, Zip Code _______________________________________________________ Daytime Phone (area code first) __________    _______________________ E-Mail Address __________________________________________________________ Choice of Payment  (check one)  __credit/debit card   __personal check   __money order If paying by personal check or money order, please make it payable to KohlQuest. Mail your check and completed registration form to: KohlQuest, 3271 Polk County Line Road, Rutherfordton, NC 28139. If paying by credit/debit card, check which card:  __ MasterCard  __ Visa   __ American Express   __ Discover Card Number _____________________________________________________________ Expiration Date (mmyy)   month _________  year _________ 3-digit security code on back of your credit card in the signature strip  ________ 4-digit code for AMEX on card front over card number to extreme right _______ Card owner's name as it appears on the credit card __________________________________________ I authorize KohlQuest, acting for Hoophole, to charge the above credit card account for the amount of registration fees indicated on this registration form. [Your signature must appear in order to pay your registration fee by credit card.] _________________________________________________________________________________ To fax your registration and pay by credit/debit card, print out and fill in this form and dial: 828  286  9786. Write the name of the courses, classes, workshops, or retreats you wish to attend, the dates for each session you have selected, and each course/class fee in the space indicated. Total the fees for each class you have registered to attend. The TOTAL is your final registration fee. If paying by credit card, that total amount is what will be charged to your credit card account. __________________________________________________ class fee  $___________ __________________________________________________ class fee  $ ____________ __________________________________________________ class fee  $ ____________ __________________________________________________ class fee  $ ____________ __________________________________________________     TOTAL   ___________ Thank you for registering. You will receive a registration confirmation via email or phone if you have no email address. Should you have any questions, do not hesitate to call 828 288 0730 or send an email to: hoophole@kohlquest.com.