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First Name:*

Last Name:*

Email:*

Company:

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Cell Phone:

Work Phone (if applicable):

Work Address:

Invoice address (street address, city, state, zip)

P.O.number (if applicable):

How did you hear about Platinum Exchange (specific name, if applicable):

Preferred location:

Payment for the program is due in full prior to the first class session. Note: In an effort to not raise the price of our program, we do not accept credit cards at this time. We will accept personal checks if you need to pay first and have your company reimburse you. If you have any questions, please send us a note through our contact form.

By checking here I understand that my registration is not complete until I have made payment arrangements.*

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