100 Treatment Practicum (Group Discount) Enrollment Agreement – 100 Treatment Practicum (Group Discount) Advanced Laser Institute919 W. Gray St. Houston, TX 77019First and Last Name* First Last Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Apprentice License NumberSocial Security Number*Upload A Copy Of Your Driver’s License*Max. file size: 5 MB. Upload Your High School Diploma/GED Or A Higher Degree*Max. file size: 5 MB. 100 Treatment Practicum (6hrs.)Group Discount: $750.00METHOD OF PAYMENT: choose one
