Gift Session Order Form by IL716Q

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									                                              Maureen McHugh
                                              Feldenkrais Practitioner




                             Gift Session Order Form

1. Name of the Giver ___________________________________

2. Name of the Recipient _________________________________

3. Number of sessions and value of the gift
    □ 1 x $110 = $110
    □ 2 x $110 = $220
    □ 3 x $110 = $330
4. Certificate delivery details

    □ Mail the Certificate to this address: ___________________________________
    __________________________________________________________________

    □ Email the Certificate to this address: __________________________________
5. Copy of the Certificate details

    □ Mail a copy of the Certificate to this address: ____________________________
    ___________________________________________________________________

    □ Email a copy of the Certificate to this address:
    ________________________________

6. Payment details
    □ Personal check via US mail
                                                                      Thank you for your order
    □ Email invoice (see web site for link)

                                                                                              October 2011


           Landmark Towers, 101 S. Whiting Street #306, Alexandria, VA 22304   703-751-2111
           mmchugh@wellnessinmotion.com         www.wellnessinmotion.com

								
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