BALM 12 Principles Weekend Registration Form

Payment Commitment Form

PAYER INFORMATION
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purchase Information

Service or Product
12 P Deep Dive Weekend

$497
12 P Deep Dive On-Demand

$497
Discount Coupon
We collect funds through ACH/Direct Deposit

Please provide the following:
Routing Number
Account Number
We will then draw funds from your account.
Signature*

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Date

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Date
Please call 1-888-998-2256 for any questions you may have.
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