Seminar Application Form

SALON/AGENCY

Last Name:	First Name:	MI:

Today's Date: 05/23/2013

Seminar of Choice:
Date:

Salon Tel:

Are you a: New Customer Existing Customer

Mobile Tel:

Previously Liscio Certified: Yes No

If No, other TR or relaxers experience?

Current Position at the salon:

Salon/Agency Name:

Salon/Agency street address:

E-mail:

City:	State:	Zip:

Fax: