PLEASE PRINT WORKSHOP REGISTRATION FORM

NAME                                                                                                                          

ADDRESS                                                                                                                     

CITY/STATE/ZIP                                                                                                         

PHONE  DAY                                                EVE                                                        

E MAIL ADDRESS                                                                                                                

DATE OF BIRTH                                                                                                                  

                             month                                      day                       year

TIME OF BIRTH                                       Circle          AM             PM                      

CIRCLE SOURCE OF BIRTH TIME:    BIRTH CERTIFICATE      OR    OTHER (Explain)

(Explain)                                                                                                                       

CITY and STATE OF BIRTH                                                                                      

 CHOOSE ONE         

A)      WHERE YOU WERE ON YOUR MOST RECENT BIRTHDAY

City/State                                                                                                                      

OR

B)      WHERE YOU'LL BE ON YOUR UPCOMING BIRTHDAY

City/State                                                                                                                                  

SEND THIS FORM AND CHECK FOR $125 TO:

                   SIGNE QUINN TAFF, P.O. BOX 2457, SEDONA AZ. 86339

All applicants are advised and notified that Signe Quinn Taff will review the above application prior to acceptance.  Ms. Taff and her staff reserve the right to reject applications for any basis deemed appropriate by Signe Quinn Taff alone.  If the application is rejected, you will receive reimbursement for all checks attached to the application.  If your application is accepted, the form will act as the registration and you will receive a confirmation from Signe Quinn Taff.  No one will be allowed admittance without written acceptance and confirmation of the registration from Signe Quinn Taff.