DISTANCE LEARNING PROGRAM APPLICATION FORM

Name Of Course__________________________________

Date:______________________

Name: ___________________________________________

Course Materials Should Be Shipped To The Following Street Address (Not P.O. Box):

Address: _____________________________________________________________________________

City State Zip: ________________________________________________________________________

Telephone:___________________________

E-Mail Address: ______________________

I have read and understand the course description and refund policy. I know that upon receipt of equipment, books, and materials, I am responsible for payment of those items upon breaking the inner seal of the package.

_________________________________

Signature Of Applicant

Charge My Credit Card: VISA Master Card (circle one) Amount Total: __________

Card holder Name (please print)______________________________________________

Authorized Signature________________________________

Card #___________________________ Expiration Date______________

Check or Money Order Payable To The Andrews School. Payment By Personal Check Will Result In A Two-Week Delay In Shipment.

Mail Payment To:

The Andrews School

5601 NW 72nd #167

Oklahoma City, OK 73132

Or If You Prefer, Call Credit Card Information To Linda L. Andrews, Director<br>(405) 721-3555 .<br>