Cape May Early Morning

Speech
Accent
Solutions.com:


Welcome to SpeechAccentSolutions.com!

Contact Information

REGISTRATION/INTAKE FORM                                   

Please feel free to copy the text of this form, fill out the appropriate fields and
if you prefer, email* (or send by US Mail) to:
 
workshopinfo@SpeechAccentSolutions.com
*Notice:  Users are reminded EMAIL is not a secure medium.  Personal information sent via the Internet can be intercepted. You may, therefore, wish to reconsider the advisability of sending email messages that contain certain sensitive, personal information to this Internet address.

Date  _______ /_______ / _______ 

Name: Mr./Ms. ______________________________________ Contact Phone (       ) _______________

Best Time to Call __________________          Wk Phone (       )  ______________________

(If contacting us for someone else)                                            

Client Name______________________________________________

Address ________________________________________________   

City ________________________ State _______ ZIP ___________ 

Email Address ________________________ School or Company Name ________________________

Native Country_________________________ Native Language _______________________________

How did you hear of us, please? ________________________________________

Reason for contact: 

To register for a service:  _______        Name of service: ______________________________________ 

To request materials:  _______             Name of materials:_____________________________________

To confirm I made a payment:  _______   Date of payment: _______  / _______  / _______ 

Amount:  ____________  Method of Payment:  MAIL: _______  email: _______  PayPal :_______ 

Other Comments/Requests: ____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Thank you for your interest.  We will respond as soon as possible.

Sincerely,

K. Bruce Harpster, M.A., CCC-SLP

Valid HTML 4.01 Transitional

SpeechAccentSolutions.com,  a speech-language and communication website.
Questions?  For more information or an appointment...  Call: 908-930-8719  Email: kbharpster@SpeechAccentSolutions.com 
                                                                                 
Mail:                                       Office (by appointment):
                                                                                    P.O. Box 326                                
200 Middlesex-Essex Tnpk, Suite 306
                                                                                    Metuchen, NJ 08840                    Iselin, NJ  08830.
  K. Bruce Harpster 2007