West Coast Jeet Kune Do Submission Conference
November 13 - 16, 2003
Featuring Larry Hartsell - Erik Paulson
Location: Inosanto Academy of Martial Arts

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Conference Registration: 
All Conference Participants are required to register with the Jun Fan Jeet Kune Do Grappling Association.  
Please submit the form by faxing or mailing to::
- Jun Fan Jeet Kune Do Grappling Association
- PO Box 9424, Marina Del Rey, California 90295 
- Fax/Tel: 310-827-1733 - E mail: jkdassoc@aol.com
- URL:  www.jkdassoc.com - Official Domain

Payment: 
- We accept Master Card, Visa, American Express and Diners Club.
- Personal/Company checks (must be post marked and received by November 3, 2003.
- No personal/company checks will be accepted at the door. No Exceptions!
- Bank Drafts, Money Orders, Travelers Checks (Payable to: Larry Hartsell)
- Mail to: Larry Hartsell - PO Box 9424 - Marina Del Rey, CA. 90295 - USA

OPTION 1:  Complete the form and Print/Mail or fax to the Association.
OPTION 2:  Secure Online Registration Link 
OPTION 3:  Pay us with PayPal

  Price Code Registration
$100.00
 WO00015
Thursday Only		 Pre- registration - Thursday, November 13, 2003.
Please include the Inosanto Academy classes with my pre- registration.
Registration - At the door $120.00
$100.00
 WO00016
Friday Only		 Pre- registration - Friday, November 14, 2003.
Please include the Inosanto Academy classes with my pre- registration.
Registration - At the door $120.00
$100.00
 WO00017
Saturday Only		 Pre- registration - Saturday, November 15, 2003.
Please include the Inosanto Academy classes with my pre- registration.
Registration - At the door $120.00
$100.00
 WO00018
Sunday Only		 Pre- registration - Sunday, November 16, 2003.
Please include the Inosanto Academy classes with my pre- registration.
Registration - At the door $120.00
$350.00 WO00019
Thursday - Sunday		 Pre- registration - Thursday, November 13 - Sunday, November 16, 2003 (4 days)
Please include the Inosanto Academy classes with my pre- registration.
Registration - At the door $375.00

Continued


 

Participant Bold = Required ltaIic = Optional

Bill To (If Different):

First Name:

Last Name:

Email Address:

Phone Number:

Fax Number:

Company:

Address:

City:

State/Province:

Indicate

Other State/Province:

Zip/Postal Code:

Country:

Credit Card Address Verification:

First Name:

Last Name:

Email Address:

Phone Number:

Fax Number:

Company:

Address:

City:

State/Province:

Indicate

Other State/Province:

Zip/Postal Code:

Country:

The billing address must match the bill to address located on your credit card statement..

 

Payment Method:

Credit Card

Type: Visa, Master Card, American Express, Diners Club International

Cardholder Name

Card Number

Expiration Date

09-04 - Example - Security Code last 3 or 4 numbers
on the back of your credit card following your account number.  
Example: Visa/Master Card: XXXX-XXXX-XXXX 2234.

American Express is the first four numbers directly above your credit card number. 
Example: 8756. Diners Club International does not require a Security Code.
OUR POLICY....No Refunds or Credits!

Please Print Name:                                                      __   Signature                      _____                                      Date: __ - __ - 03.

 I hereby authorize the Jun Fan Jeet Kune Do Grappling Association/Larry Hartsell to debit  the amount specified above to the designated credit card.  

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