Relationship Consultant and Coaching for Relationship Help

To confirm your booking, please complete and submit this form. Ali will contact you to confirm your booking dates and on receipt of proof of payment, your booking will be confirmed. A letter of confirmation will be emailed or faxed through to you. Please ensure that you receive it.

PLEASE PROVIDE FULL DETAILS (items marked with * are mandatory):

*Your name:
Referred by:
*Tel:
*Cell:
Fax:
*Email:

Can we send emails of a
confidential nature
to this address:

Share the fun with your friends:

1. Friend's Name:
1. Friend's Contact Tel:
1. Friend's Email:

2. Friend's Name:
2. Friend's Contact Tel:
2. Friend's Email:

3. Friend's Name:
3. Friend's Contact Tel:
3. Friend's Email:

Expected number of attendees:
Course you wish to attend:
Preferred month for booking:
* Ali will contact you to confirm a date within your chosen month

By submitting this form, I do hereby agree that:

Full payment of the account is the responsibility of the undersigned/client
I understake to be liable for all legal costs as between attorney and client as well as tracing collection fees due, should it be necessary for legal action to be taken for the recovery of any amounts owing.
I further consent to your being entitled to obtain credit and related information concerning myself at any time and for the disclosure, lodging or exchange of such information with any credit bureau without any further notice to me.