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Name_____________________________________

Address___________________________________

City______________________________________

State_____________Zip_____________________

Country___________________________________

Telephone (___)____________________________

Fax (___) ________________________________

Email____________________________________

___Credit Card:

___ Visa ___ Master Card
___Discover___ American Express

Card #____________________________________

Exp. Date______________________

Signature__________________________________

For Cont. Ed. Credit: SS#_________________________________

___Checks (payable to Back to Basics Golf):

Check Enclosed for $_________