Primeco Education, Inc.

<%@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, Inc.

Primeco One Page
Introductory PDF Flyer

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Conspiracy for Greatness

Behnam Bakhshandeh

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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
Jump Start Your Transformation
Power & Effectiveness Course
Individual Coaching
Accountability Coaching
Family/Couples Coaching
Mentorship Program

Business Consulting
Business Consulting one on one
Executive Coaching
Team & Organization Training
Managers Training
Primeco Coaching Academy

Special Events
Business & Personal Development Seminars
Bravehearts (Leadership Development Training)
Building Blocks (Tele Classes)
" Life is Great!" Events
StakeHolders (Community Leadership Development Program)

Retainer Plan

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
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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.

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