Name_______________________________________________
Address_____________________________________________
City _____________________________ St. ____Zip________
Phone______________________________________________
Email______________________________________________
Electricity Yes___ No ___
Product ______________________________________________
Make checks payable to: Mid-America Hypnosis Conference PO Box 2731, Northlake, IL 60164
Fax Number: 847-455-0890 E-Mail: mrcarm@aol.com : 847-451-9303