Instructions: 1. If you wish to pay by check: Please print this form and fill it out completely. Send the form AND a check made payable to Revolution Prep to the following address: Revolution Prep 710 Wilshire Blvd. Suite 501 Santa Monica, CA 90401 2. If you wish to pay by credit card through our Fax Order Service: Please fill out your credit card billing information at the bottom of this form, and fax the completed form to 310-458-7292 (FAX) 3. Once enrollment is processed, you will receive an email confirmation. Note: FORMS WILL NOT BE PROCESSED WITHOUT PAYMENT * indicates a required field
Student Data: 1. First Name*
8. Address*
2. Last Name*
9. City*
3. Home Phone*
10. State*
4. Alternate Phone
11. Zip Code*
5. Student Email*
12. High School*
6. Parent Email
13. Graduation Year*
7. Student Date of Birth*
14. How did you hear about us?
Course Details: 1. Preparing for (circle one):
2. Course Type (circle one):
SAT ------>
Jan 24
Mar 14
May 2
ACT ------>
Feb 7
April 14
June 13
Hybrid (Course + 4 hrs tutoring) - $799
3. Class Location* :
June 6
Standard Group Course - $499
Online Upgrade - $99
4. Class Night* :
Credit Card Info (if enrolling through Fax Service) : 1. Name on Credit Card* : 2. Card billing address (if different from student address):
VISA
MC
DISCOVER
3. cc*: mo / yr 4. exp*:
1-877-REV-PREP www.revolutionprep.com
5. today‘s date* :
710 Wilshire Blvd, Suite 501, Santa Monica, California 90401 phone: (877) 738-7737 • fax: (310) 458-7292