"Extreme products for the serious martial artist."
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"Extreme products for the serious martial artist."
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Reservation
Form N.I.P.P.A.
Instructor’s Certification Course Please
phone, fax, or mail this order form to: Bushido Productions, Inc.,
Please reserve my place in the N.I.P.P.A. Instructor’s Certification course I have enclosed my non-refundable deposit of $500 (check, money order, or
credit card information). I agree to pay the balance of my fee no later than
two weeks prior to the start of the course. Name: __________________________________________________________________________________ Address: ________________________________________________________________________________ City: Zip/Postal Code: _______________ E-Mail Address: ____________________________________________ Home Phone: ___________________________________ Other Phone: _____________________________ Age: ______ Years of Martial Art Training: ______
Credit Card Payments Credit Card: ____ Visa ____ Mastercard ____ American Express ____ Discover ____ Diner’s Club ____ JCB Credit Card Number: ______________________________________________________________________ Three Digit Code on Back of Credit Card: ______ Expiration Date: ____________________________ Authorized Signature: ______________________________________________
Name & Billing Address for Credit Card Payments (If Different from Information Provided Above) Name: __________________________________________________________________________________ Address: ________________________________________________________________________________ City: Zip/Postal Code: _______________
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