NEWSLETTER
AND KCC SEMINAR
REGISTRATION FORMS

Please provide the information you would like added to your entry on KCC's Customer Mailing List. KCC will send a copy of our monthly newsletter to you via email. If you wish to register and authorize payment for the next KCC seminar, please complete the Payment Information section (4) below. AOL USERS: If you are using the AOL browser (version 3 or lower), this order form may not be sent correctly automatically when you click the SUBMIT button at the end of the form. Instead, you must either: 1. PRINT the form on your local printer and send it with check or money order to our address or, 2. Call up your standard email window and type in the required information there to be sent to cocained1@aol.com as standard email text. We apologize for the inconvenience. We are currently working to resolve this technical problem with AOL. NOTE: THOSE AOL USERS WHO HAVE SENT ORDER FORMS TO US DURING THE FIRST FEW WEEKS OF AUGUST 1998 SHOULD CONTACT US VIA EMAIL OR PHONE TO VERIFY THAT WE HAVE RECEIVED THEIR INFORMATION. 1. General information about yourself. Last Name First Name Your Address Apt # City State ZIP Your Email Address Home Phone Calling Hours Work Phone Work Calling Hours Pager Cell phone 2. In which KCC services are you interested? To select more than one item on the menu below, hold down your control key and click your left mouse button. Mailing List (Free) Free Newsletter KCC Seminar (Chicago Office only) $195 Personal Instruction Services Co-Training Services If you have selected the KCC SEMINAR REGISTRATION Option above, you must complete the next section of this form. If you have concerns regarding internet privacy and security, we recommend that you complete this section but omit your account numbers. After you submit this form, you must then phone us at (773) 685-2735 and provide us with your account information in order to secure your reservation. Click her for MAPS indicating the location of our Chicago Offices. (Optional) Briefly describe your situation and background: 3. How did you hear about us? Internet. . . On which search engine? Another web site. . . . On which site? . Indicate that site's URL: Friend Work School Television Newspaper Magazine Radio Chicago Reader Chicago Sun Times Chicago Trib Flyer Business Card Yellow Pages Repeat Customer . . . . Referred by a friend . . . . Other 4. Payment Information Credit Card Card Number Exp. Date If you intend to pay by check, please complete the following section and mail your check as soon as you submit this form. Bank Name Bank ID No. Bank Account No. Check No. When you submit your credit card information via this form or by submitting your credit card information via telephone, you are authorizing a $195.00 charge to your account to secure your reservation in the next KCC SEMINAR. If you wish to save a copy of this form for your records, we recommend that you select FILE and then SAVE AS from your browser menu. You may wish to name the file "KCC order form" and save it to your "MY DOCUMENTS" folder. Thank you for visiting the KCC web site. Please feel free to email or call at any time. Note: If a Security/Privacy Warning appears after you click the 'SUBMIT' button below, you must click 'OK' in order to proceed with the submission of the form to KCC. Again, if you are not entirely comfortable with the transmission of your credit card or account number information via the internet, we recommends that you omit those numbers from this form, submit the form, and then telephone us with your account number information.