UNLEASH THE GODDESS WITHIN REGISTRATION FORM How did you find out about this program?*Path of the Goddess Facebook PostIntroduction SeminarFriend/ReferralTamika HilderExpoOtherWhat was the seminar date and location?Friend/Referral Name:Name* First Last Date of Birth: Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone*Email* Please Select Your Date From The Drop Down*Select Dates11-13 October 2019There are four payment options. There are 3 early bird options. Early bird Option #1: Pay $1200 upfront. This amount must be paid in full, in one payment. The cut off date for this option is 2 month before the program start date. Early bird Option #2: 3x Monthly Payments of $500. Total of $1500. Early bird Option #3: 5x Monthly Payments of $300. Total of $1500. The balance for the earlybird payment plans is required to be paid in full, 2 months prior to the program start date. If you’re unable to pay the balance in full by the cut off date, then you will be moved to the next available program. Option #4: If you miss the early bird option, then don’t worry - we have the standard price of $1990. Payment Plan Note: Payments are processed securely through Stripe using your credit card. Your credit card will be automatically and conveniently charged each month until your payment plan is complete. Select Price:*$1990 - Standard Price$1200 - Earlybird Pay Upfront3 x monthly payments of $500 - Earlybird Payment Plan5 x monthly payments of $300 - Earlybird Payment PlanCoupon Total $ 0.00 Please Select Your Payment Method:*Pay Via Credit CardCredit Card* DiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Security Code Cardholder Name SSL CertificatePayment Option 2: Direct Debit into: Evolve Humanity Foundation BSB: 06 4145 ACC: 1034 3177 Please email your payment remittance to email@example.com and place your first and last name and name of program as reference.1. I agree to the above service and to paying for the program in full by the due date which is two months prior to the event date. If payment is not made in full, follow up will occur by us or a professional agency. I am aware that I am making acommitment to attend this program. 2. I agree that this is a non-refundable payment/deposit. I agree to a cooling off period of 3 days. If I change my mind within 3 days, I must contact the Path of the Goddess team in writing by email and I am entitled to a refund of the full amount I have paid. 3. If however, I change my mind after the cooling off period, I am not entitled to a refund and cannot use this payment toward any other service other than a future Level 1 event. The event must be attended and paid for within 12 months of the original date of registration. 4. If for whatever reason, I need to reschedule this event, I can do so as long as it is not within 6 weeks of the event date. If I reschedule within 6 weeks of the event, I lose my place and my full payment.