Primeco Education

<%@LANGUAGE="VBSCRIPT"%> <% if (cStr(Request("Submit")) <> "") Then Dim MailObj,interest,interest2,interest3,interest4,interest5 Subjectai = "Website Registration Form Enclosed" TextBody ="**** W E B S I T E R E G I S T R A T I O N F O R M ****" & vbCrLf & "****************************************************************" & vbCrLf & vbCrLf & "------------------- Applicants Information ---------------------" & vbCrLf & vbCrLf & "Name: " & Request.Form("FName") & " " & Request.Form("LName") & vbCrLf & "Address: " & Request.Form("Address") & " - " & Request.Form("Suite") & vbCrLf & "City, State, Zip: " & Request.Form("City") & ", " & Request.Form("State") & ", " & Request.Form("Zip") & vbCrLf & vbCrLf & "Work Phone: " & Request.Form("Work_Phone") & " Home Phone: " & Request.Form("Home_Phone") & vbCrLf & "Cell Phone: " & Request.Form("Cell_Phone") & " Fax Number: " & Request.Form("Fax") & vbCrLf & vbCrLf & "Email: " & Request.Form("Email") & vbCrLf & "Interested in: " & Request.Form("Interest") & vbCrLf & vbCrLf & "-------------------- Managers Information ----------------------" & vbCrLf & vbCrLf & "Name: " & Request.Form("Managers_Name") & vbCrLf & "Title: " & Request.Form("Managers_Title") & vbCrLf & "Phone: " & Request.Form("Managers_Phone") & vbCrLf & "Email: " & Request.Form("Managers_Email") & vbCrLf & vbCrLf & "-------------------- Referral Information ----------------------" & vbCrLf & vbCrLf & "Referred by: " & Request.Form("Refered_by") & vbCrLf & "Other: " & Request.Form("Other") & vbCrLf & "Name: " & Request.Form("Friends_Name") & vbCrLf & "Phone: " & Request.Form("Friends_Phone") & vbCrLf & vbCrLf & vbCrLf Set MailObj = CreateObject("CDO.Message") MailObj.From = "info@primecoeducation.com" MailObj.To = "behnam@primecoeducation.com" MailObj.CC = "" MailObj.Subject = Subjectai MailObj.TextBody = TextBody MailObj.Send Set MailObj = nothing Response.Redirect("mailsent.htm") End If %> Primeco Education

Primeco One Page
Introductory PDF Flyer

Connect with Behnam and Primeco at these social networking sites!

Conspiracy for Greatness

Behnam Bakhshandeh

Twitter MySpace

LinkedIn YouTube

REGISTRATION

You can register via:

Telephone		Tool Free :877-942-6076 Call 760-436-6076 24 hour voice mail

Fax		Fax your information to: 760-436-6053

Email		E-mail your request and information form to: info@primeeducation.com

Mail		Mail your request and information form to: Primeco Education 240 N. El Camino Real Suite 444 Encinitas, CA 92024

Web Site Form		Please complete the form below Or Download Program Registration Form-General

Registration / Information Form

I am interested in:

Personal Coaching
Individual Coaching
Couples Coaching
Mentorship Program

Business Consulting
Executive Coaching
Team & Organization Training
Business Consulting

Public Programs
Power & Effectiveness Course
Bravehearts Program (Leadership Development Training)
Developmental Seminars

First Name	*
Last Name	*
Address	*
Suite / Apt
City	*
State	*
Zip Code	*
Work Phone	*
Home Phone
Cell Phone
Fax Number
Email	*
Approving Manager or Supervisor
Name
Title
Phone Number
Email

How did you hear about us?

Friend
Advertisement
Search Engine
Other. Please specify below

If you were referred by a friend, please allow us to thank them.

Referred by (Name)

Phone Number

You will be contacted by phone or email within 24 hours after receiving your call, fax or email.

Personal Coaching | Professional Coaching | Personal Growth