Booking Form for Libido Fundamentals w/Andrea Juhan, Ph.D. January 26-29, 2018 Please complete the form below to register your place for Libido with Andrea Juhan. You may pay by Credit Card via PayPal or Direct Deposit Banking. Name* First Last Email* Contact Phone Number*Your privacy is always respected. Please provide your best contact number - mobile is preferred. Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country This field is hidden when viewing the formBook For Libido with Andrea JuhanAll amounts are in $NZ The Early Bird price is available til 31 December 2017 From 1 January 2018 the price will be $450 $399 Early Bird $360 Open Floor Teachers In Training Only Book For Libido with Andrea Juhan* $450 $360 Open Floor Teachers In Training Only Workshop Crew OFI Working Members Your Payment Options* By Direct Deposit Banking (our preferred option) Pay by Credit Card via PayPal (you do not need a PayPal account) To pay via Direct Bank Transfer: Bank: KiwibankAccount Name: Sacred MovesAccount Number: 38-9001-0388239-05Use your full name as the reference To reserve your place, please pay within three days of submitting this form. Please note, your place is only secured once funds have been received.Once you have paid, please email us at info@openfloor.co.nz to let us know - thank You! To help Andrea during Libido, please upload a photo of yourself:Please make sure your photo is large enough for printing. The ideal size is about 1mb in size or roughly 1000px square. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB, Max. files: 2. Terms and Conditions (must be checked)* I Have Read The Terms And Conditions: If for any reason you need to cancel your event booking, your tuition fees will be fully refunded, minus a $50 administration fee, if cancelled before 1 January 2018. Cancellations after 1 January 2018 will only be refunded (minus $50 administration fee) if your place can be filled from the wait list. The venue, dates and timings are subject to change.Our Newsletter Please subscribe to your newsletter for up to date news on classes, workshops and retreats. Comments or QueriesTotal $ 0.00 PhoneThis field is for validation purposes and should be left unchanged.
