Class sizes are limited, so please register early.
Sliding-scale, student, volunteer, and government discounts available.  Inquiries welcome. 

To register, simply print out this form, complete it, and then
fax, mail, or e-mail it (see contact information below).

To view courses currently scheduled, please see our Current Offerings page.

Participant Name
Title/Occupation
Company/Organization
Address

Work Tel		Home Tel
Work Fax		Home Fax
Cell Phone		E-mail

Please indicate the program, the number of people attending, and the program dates.

Course Title	Course Dates	Tuition	Last Day to Register
___ Comprehensive Mediation Training at U.C. Berkeley (40-hour Certificate of Completion)	June 2, 9, 16, 23 & 30, 2012 (five Saturdays)	____ $995 (Payment for this course may be made at extension.berkeley.edu.)	—
___ Advanced Mediation Training	February 4, 11 & 18, 2012 (three Saturdays)	____ $750 regular tuition	—

Payment Options

____	I am paying by CHECK (made payable to "Professional Mediation Associates").
____	I am paying by CREDIT CARD.  My ____ Visa ____ MasterCard number is ________________________________, and the expiration date is __________.
____	If the name and address shown for my course registration do not match what is shown on my credit card billings, the name/address associated with my credit card is/are: _____________________________________________________________________________
____	My authorization signature:  x__________________________________________________

  

Cancellations

There is a nonrefundable cancellation fee of $150,
or you may transfer to another course within 12 months.
We reserve the right to cancel a course at any time for a full refund of your payment.
We cannot be responsible for nonrefundable travel and accommodation arrangements.

  Fax or mail your completed form, or send a scanned copy of it via e-mail, to:

Professional Mediation Associates
      

700 Larkspur Landing Circle, Suite 199

Larkspur, CA 94939

(415) 454-4478 (tel)

(415) 464-0508 (fax)

t.carey@ix.netcom.com