ENROLLMENT FORM     Step 1: Please complete and submit the enrollment form below.     Step 2: Email a current CV or resume to sbizal@drbizal.com.     Step 3: To purchase (online or by check) the wellness certification or wellness coaching certification program that you wish to attend...please scroll to the bottom of the page.  All prices are quoted in United States Dollars "USD".   Step 4: Confirmation and additonal attendee information will be sent by email within 24 hours upon receipt of completed enrollment, CV/resume, and payment.      Thank you and congratulations on taking a valuable step to EmPOWER both your career and your personal health! The fields marked with (*) are required fields. * Source: How did you hear about the Wellness Coaching Institute ?  * required * First Name  * required * Last Name  * required * Address Line 1  * required * Address Line 2  * required * City  * required * State  * required * Zip Postal Code  * required * Country United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaidjan Bahamas Bahrain Banglades Barbados Belarus Belgium Belize Benin Bermuda Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian O. Terr. Brunei Darussalam Bulgaria Burkina Faso Burundi Buthan Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos (Keeling) Isl. Colombia Comoros Congo Cook Islands Costa Rica Croatia Cyprus Czech Republic Czechoslovakia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Estonia Ethiopia Falkland Isl.(Malvinas) Faroe Islands Fiji Finland France France (European Ter.) French Southern Terr. Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain (UK) Greece Greenland Grenada Guadeloupe (Fr.) Guam (US) Guatemala Guinea Guinea Bissau Guyana Guyana (Fr.) Haiti Heard & McDonald Isl. Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazachstan Kenya Kirgistan Kiribati Korea (North) Korea (South) Kuwait Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique (Fr.) Mauritania Mauritius Mexico Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands Neutral Zone New Caledonia (Fr.) New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Isl. Norway Oman Pakistan Palau Panama Papua New Paraguay Peru Philippines Pitcairn Poland Polynesia (Fr.) Portugal Puerto Rico (US) Qatar Reunion (Fr.) Romania Russian Federation Rwanda Saint Lucia Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa Soviet Union Spain Sri Lanka St. Helena St. Pierre & Miquelon St. Tome and Principe St.Kitts Nevis Anguilla St.Vincent & Grenadines Sudan Suriname Svalbard & Jan Mayen Is Swaziland Sweden Switzerland Tadjikistan Taiwan Tanzania Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu US Minor outlying Isl. Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis & Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Other * Telephone Number  * required * Email Address  * required * Company  * required * Position  * required   Current responsibilities within your organization * Which Wellness Certification Course are you interested in enrolling? Domestic - Wellness/Lifestyle Medicine for Public Health (16 hours) @ $1495 Corporate Wellness Coach I (8 hour) @ $995 Corporate Wellness Coach II (8 hour) @ $995 Corporate Wellness Coach I & II (16 hours) @ $1495 Chief Wellness Officer "CWO" (8 hour) @ $995 Corporate Wellness Coach I & II & III (24 hours) @ $1995 International - Wellness/Lifestyle Medicine for Public Health (16 hours) @ $1495 Wellness Mastery Retreat - Health Professional @ $6995 Wellness Mastery Retreat - Executive @ $4995   Which program date and location do you wish to attend? July 31-August 1, 2010 in Czech Republic August 7-8, 2010 in Czech Republic September 4-5, 2010 in Costa Rica September 25-26, 2010 at SCUHS Campus, California, USA December 4-5, 2010 at SCUHS Campus, California, USA
Licensed Health Professional (MD, DO, ND, DC, DrPH, PhD, LAc)  purchase online... Introductory Price Special for 2010   "Wellness/Lifestyle Medicine for Public Health" $1495 ... Buy Now!     or Pay by Check... Make your check payable to: The Bizal Group, Inc. Mail your check to: The Bizal Group, Inc., 4533 MacArthur Blvd., Ste.A #166, Newport Beach, CA 92660	Insurance  Professionals  Purchase online... (programs may be purchased separately or as a package) Wellness Agent "I" @ $495 ...Buy Now! Wellness Agent "II" @ $495 ...Buy Now! Chief Wellness Agent "CWA"  @ $495 ...Buy Now!   Package Price #1 (save $241) Wellness Agent "I" + "II" $749 ...Buy Now! Package Price #2 (save $488)  Wellness Agent "I" + "II" + "CWA" $997 ...Buy Now!    or Pay by Check Make your check payable to:  The Bizal Group, Inc. Mail your check to:  The Bizal Group, Inc., 4533 MacArthur Blvd., Ste.A #166, Newport Beach, CA 92660	Human Resource Professionals  purchase online... (Programs may be purchased separately or as a package) Corporate Wellness Coach "I"   $495...   Buy Now! Corporate Wellness Coach "II"  $495...   Buy Now! Chief Wellness Officer  "CWO"  $495...   Buy Now!      Package Price* #1 (Save $241) * Corporate Wellness Coach "I" + "II"  $749...   Buy Now! Package Price** #2 (Save $488) ** Corporate Wellness Coach "I" + "II" + "CWO" $997... Buy Now! or Pay by Check... Make your check payable to:  The Bizal Group, Inc. Mail your check to:  The Bizal Group, Inc., 4533 MacArthur Blvd., Ste.A #166, Newport Beach, CA 92660
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