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EMF Balancing Technique®
Web Site Listing & Contact Details 

This form serves two purposes - Information to post online to the public (the way the public contacts you), and information for the EEI data base (the way EEI contacts you).

Please submit this form in the same envelope with your original signed License Agreement and payment for yearly fee if you wish to be listed on the Multi-Language www.EMFWorldwide.com web site - The official English version - The EMF English Language Mirror Site. The ONLY comprehensive source of information in English, providing consistent information to all English speaking visitors on the Internet. We highly encourage you to send your information so that your name can appear with all the other licensed Practitioners. This is an important outlet for you to promote your practice

This entire form MUST be TYPED and a hard copy submitted to EEI

*Part A - Web Site Listing Information (optional)

*If you do not wish to be listed at this time go to Part B.

 
   First Name    Last Name
 Address: 
City, Province, or Canton:
   State:
Zip Code or Postal Code:    Country:

Email:
Telephone Number:
 
                     (include country code if outside of USA)                     

Level: Please check all that apply:
Advanced Certified Practitioner        Phases I-VIII Certified Practitioner 
Accredited Practitioner Phase I-IV
       Accredited Practitioner I-IV and Practitioner V-VIII

Part B – EEI Data Base Contact Details  

If your contact details for EEI are the same as Part A check here
 
 
If your contact details are different from Part A, please TYPE below how you wish to be contacted by EEI 

First Name   Last Name
Address: 
City, Province, or Canton:
   State:
Zip Code or Postal Code:   Country:
Email:
Telephone Number:  

Part C – Yearly Web Listing:
Basic Listing - Includes information from Part A only. $22.00usd for 1 year*.
Basic Listing & Link to your personal Website - $55.00usd for 1 year*.
     Web Site Link:

Payment Method:
Check in USD, Drawn on a US Bank
(please include the check with this form, payable to EEI)
Transfer to Germany Account
(Click Here for Transfer details)
USD Money Order
(please include the money order with this form, payable to EEI)
Credit Card
 (Visa, Mastercard, Amex, or Discover)

Credit Card Number
  Name on Card   
Expiration Date


Mail in the same envelope: a hard copy of this form (must be typed) with the original (not a copy) signed License Agreement and payment (if any - for web listing) to:
The Energy Extension Inc. Att: License Dept.
PO Box 4357, Sedona, AZ 86340, USA