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NLP 40 Year Celebration and Success Factor Modeling™ Certification Enrollment Form 2015

with Robert Dilts and Special Guests

Teresa Epstein - NLPU Coordinator
Phone: (831) 336-3457
Email: teresanlp@aol.com

Enroll for the festivities on campus at the beautiful University of California
in Santa Cruz.
Prerequisite Free ⁓ Everyone is Welcome

We guarantee that if for any reason you need to change your plans, we will fully refund your money minus a $250 cancellation fee.

  • Arrival August 16 12–2 PM and Departure August 24 4 PM
  • Enrollment is OPEN!
  • Reserve your option TODAY by contacting Teresanlp@aol.com 831-336-3457

    • Your Name:
    Name as It Should Appear on Your Certificate:

    Your Mailing Address:
    Street:
    Apt. or Suite:
    City:
    State/Province:
    Postal Code:
    Country:

    Your Email Address:
    Your Telephone Number:

    Please list any relevant professional qualifications that you have:
    Please list any NLP certifications you have received.
    Include the level, trainer(s), organization and date:

    NLP 40 YEAR CELEBRATION ENROLLMENT OPTIONS

    Residential Package: $3,100 US dollars. (Includes Robert Dilts Learning Materials, tuition, private accommodations, meals.)
      Male Female
    Couples Residential Package: $5,396 US dollars. (Includes Robert Dilts Learning Materials for two, tuition for two, double accommodations, meals for two participants.)
      Name of other participant:
    Tuition Only: $1,975 US dollars. (Includes Robert Dilts Learning Materials, tuition.)

    Couples Tuition (10% discount): $3,556 US dollars. (Includes Robert Dilts Learning Materials for two, tuition for two.)

    Deposit to be applied toward total fees: $500 US dollars. (Holds your place in the International Celebration.)
    Grand Total for all Fees $
    Deposit amount authorized $ Balance Due on or Before June 1st $

    METHODS OF PAYMENT

    Bank Check - NLPU prefers that you send a check in US dollars. At your bank you can ask for a check to be made out to NLP University and then send it to:
      NLP University, P.O. Box 1112, Ben Lomond, California 95005. USA
    or

    Bank Transfer - If you would like to make a bank transfer, please transfer in US dollars to the NLP University Checking Account:
      Bank of America, 300 S Holladay Dr Seaside, Oregon 97138 USA
      Telephone: 503 738-8311
    This is all you need:
      Swift Code: BofAUS3N
      NLP University Checking Account: 485003913764
      Wire transfer routing # 026009593
    or

    Visa Mastercard (Sorry, no American Express)
      Card Number
      Expiration (Month/Year) 3 Digit Code on Back
      NOTE: For added security, you may send the credit card numbers in 2-3 separate emails.

      Deposit Authorized Now $
    or

    Some Cash US Dollars can be paid at Registration.

    or

    A Payment Plan, guaranteed with a Visa or Mastercard, can be arranged.

    If you decide to cancel for any reason, all the money you have paid is 100% refundable, minus a $250.00 cancellation fee.

    Please make checks payable to NLP University and submit your completed enrollment form to reserve your place.


    CONFIDENTIAL PARTICIPANT INFORMATION

    Please read carefully, answer and confirm accuracy.

    Are you or have you recently been using any kind of medication? Yes No
    If Yes, please explain:


    Are you now or have you recently been under the care of a doctor, psychiatrist or psychologist? Yes No
    If Yes, please explain:


    Is there a history of mental illness in your family? Yes No
    If Yes, please explain:


    Do you have physical problems or disabilities for which you will need assistance? Yes No
    If Yes, please explain:


    If you are currently under the care of a doctor, psychiatrist or psychologist, please provide us with the appropriate contact information below, including telephone numbers:
    1. Name: Telephone:
    2. Name: Telephone:

    The University of California, where NLPU is held, does not allow inappropriate use of drugs or alcohol on campus. Please indicate if you have had a dependency problem: Yes No

    Emergency Contact Information All participants, please provide the names and telephone numbers at work and home for two people that we can be in contact with in case of an emergency:
    1. Name:
      Work: Home:
    2. Name:
      Work: Home:

    The participant clearly understands: the education being provided is solely for the avocational / recreational purposes and is not intended to provide training for employment. Such education is being pursued for personal entertainment, recreation, individual edification or as a hobby.

    Participants at NLP University are expected to behave respectfully and ethically toward fellow participants, NLP University and University of California staff. Participants who disrupt the educational flow of NLPU with inappropriate behavior will not be assessed for certification and may be asked to leave the campus.

    NLP University's right to deny entry into a program is reserved.

    The University campus is a special learning environment. We feel privileged to offer these NLP programs at the UCSC campus, where NLP was founded. NLPU tries to maintain an environment conducive to learning and appreciates your cooperation with these guidelines. Please feel free to check with NLP University if you have questions.

    Thank you.for your consideration.

    I confirm that I have read and understood the above policies and that the answers I have provided are accurate and complete. Date:

    Click here to when done.

    Thank you.

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