Restoration Therapy Course (150 hrs) 

Application Form  

Beginning Course          Advanced  Course   (Circle one)

 

         Name_______________________________________________________

 

        Address______________________________________________________

 

        City____________________________ State_________  Zip______________ Dojo___________________ Rank_____________

 

        Phone  Home.___________________ Work__________________ E mail_______________________

 

            Full payment required with application     Amount $___________       $725.00 before 3/01/08   $775.00 after 3/01/08

            Check    Cash     Money Order  (Circle one).

                                                                                                            Print and Mail to:

Kodenkan Restoration Therapy

1196 South De Anza Blvd

San Jose, Ca. 95129

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