This registration and payment form is for those already accepted into a class at Executive Coach Academy and those who are paying for a class, seminar, workshop or personal growth weekend seminar.
Please print this form and fax to our secure fax line, 212-873-6809.

Credit card information:
[  ] MasterCard [  ] Visa

Total cost billed to credit card: $__________________________

For any class or seminar over $ 1,000, you may elect to have your credit card billed 1/3 of the total tuition cost over three months. We will add a five per cent administrative fee in doing so.
If you are choosing this option check here [  ]

Calculate tuition amount plus ten percent and divide by 1/3.
That amount is: $________________________
I understand my card will be billed this amount over the next three months, starting with the first day of each month. Initial here. [  ].

Name as it appears on credit card_________________________
Company name (if applicable)________________________
Address on credit card________________________________________________
City & State______________________________________  
Zip code___________
Account number of credit card__________________________
Expiration date______________________
Signature_______________________________
Date___________________________________

I agree that I am responsible for these payments and that I understand this agreement. Note: Credit card invoices will show bills paid to Robinson Capital Corp, the corporation that owns Executive Coach Academy. Payments by check should be made directly to Robinson Capital Corp. at the address listed at the bottom of this application.Cancellation policy: I understand that I may cancel my enrollment before the second day of classes for any class, workshop or program that takes place over several months. In such cases, I understand I am responsible for paying the costs of all workbooks used or assessments taken and those will be charged to my credit card or billed to my company or to me.Executive Coach Academy reserves the right to accept or reject any applicant that it sees fit based on our own private selection criteria. We do so without regard to race, creed, gender, sexual orientation or religious affiliation.
We actively encourage minority applications to apply to our program and sometimes are able to offer small financial stipends to minority applicants attending our programs.

Send this application via fax to 212/873-6809.
www.executivecoachacademy.com, a division of Robinson Capital Corp.
201 West 74th Street, Suite 14F, NYC 10023.
Phone: 212/ 501-8991.
If payment is being made by check please make out check to Robinson Capital Corp and send to Robinson Capital Corp., 201 West 74th Street, Suite # 14F, NYC 10023.