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
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