Class Date________________ For Credit Card orders Fax
Name___________________________________ this form to: (860) 873-2181
Company Name___________________________ OR Mail with your check payable to:
Address_________________________________ G. Rucker Associates, LLC
City_______________State______Zip_________ P. O. Box 302
Phone________________Fax________________ East Haddam, CT 06423
Email___________________________________ Circle one: Visa Mastercard
Additional Registrants: Total:$_____.__Exp. Date__/__/_______
1)______________________________________ Credit Card #______________________
2)______________________________________ Name on Card______________________
Signature:_________________________
