Mail Or Fax Your
Coaching Program Enrollment

Please print out the following and either:

1. Fax it to (434) 978-0118

2. Mail it to:

Ultimate Lifestyle Academy
690 Berkmar Circle
Charlottesville, VA 22901

Please fill in the checkbox at the left for the 7 Power Centers of Life Coaching Program option you prefer:

*

Coaching Program Description

 

Initate: $30 Appreciation expressed per month, automatically expressed via credit card

Adept: $150 Appreciation expressed per month, automatically expressed via credit card

I'd like to express Appreciation by using the following credit card (please check one):

Mastercard Visa
American Express Discover/Novus

Credit Card Number: _________________________________________

Expiration Date: ____________________________________________

Authorization:
I authorize Ultimate Lifestyle Academy to process my expression of Appreciation on my credit card as specified above for Phase 2 Coaching Program option specified above.

 

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(please sign your name above)

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