EmailMe Form - Course Assistance Form

Name *

First Last

Email *

Phone *

### - ### - ####

Today's Date: *

MM / DD / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Training/Course Name: *

Date of Training/Course: *

1.Training Course Fee: *

$ Dollars . Cents

2. Required Contribution Amount : 25% of Line 1 *

$ Dollars . Cents

3. Your Portion of Training/Course Fee (50% of Line 1): *

$ Dollars . Cents

4. Add Lines 2 and 3: (Amount due if paying by Zelle or by Check) *

$ Dollars . Cents

5. PayPal Fee (2.5% or .025 of Line 4) *

$ Dollars . Cents

6. PayPal Amount Due (Add Lines 4 and 5) *

$ Dollars . Cents