POP! Stand Out In Any Crowd

Application for Sam Horn’s POP! Institute Use your "back" button to return.

You may register by mailing this form (first come – first served) to Action Seminars,

ATTN: Cheri Grimm at P. 0. Box 6810, Los Osos, CA 93412 or fax to (805) 528-2581.

Questions? Call Cheri at our toll free number 800 SAM-3455 or email info@samhorn.com.

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Name: _____________________________________________________________

Company : _____________________________________________________________

Address: _____________________________________________________________

City, State, Zip : _____________________________________________________________

Phone Number: ____________________ Fax Number: ____________________

E-mail: _____________________________________________________________

Current Position and Primary Job Responsibilities:

__________________________________________________________________________________________

Speaking/Coaching Experience:

__________________________________________________________________________________________

Why do you want to become a certified POP! Presenter or Consultant?

__________________________________________________________________________________________

What additional experience/talents/background do you have that qualify you to become a

POP! Presenter or Consultant?

__________________________________________________________________________________________

What do you intend to do with your certification if you successfully complete the POP! Institute program?

__________________________________________________________________________________________

Any other comments on why you'd like to become a certified POP! Presenter or Consultant?

__________________________________________________________________________________________

Please indicate which type of POP! certification you’re applying for:

Internal POP! Presenter or Workshop Facilitator . . . This plan is for Marketing Specialists, Creative Directors, Customer Service Managers, Ad Supervisors, etc. who intend to use their certification within their organization to conduct POP! programs for employees. The licensing agreement and fee paid for this plan lasts one year from the date of certification. It can be renewed, subject to approval by Sam Horn and/or Cheri Grimm, and upon payment of the annual re-certification fee. Cost: $3500 ____

Paid POP! Presenter or Consultant. . . This plan is for entrepreneurs who plan to book POP! speaking engagements in the public and private sector, and/or offer POP! consulting/coaching services. These individuals are welcome to generate and schedule their own fee-paid speaking engagements (i.e., convention keynotes, public seminars, small business workshops), and will also be represented by the POP! Presenter and Consulting Network. The licensing agreement and fee paid for this plan lasts one year from the date of certification. It can be renewed, subject to approval by Sam Horn and/or Cheri Grimm, and upon payment of the annual re-certification fee. Cost: $3500 ____

Method of payment: check _______ (please make payable to Action Seminars)

Credit card # _____________________________________________________

Exp. date _______________________________________________________

Signature _______________________________________________________

A deposit of half the certification fee is to be submitted with your application form. (This will be returned if, for some reason, your application is not approved.)

The balance owed is due one week before the POP! Training Institute.

Refund requests must be made in writing, and will be given (minus a $100 processing fee), up to one week before the POP! Training Institute. No refunds given after that time, although the certification can be re-scheduled in case of emergency.

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You may register by mailing this form (first come – first served) to Action Seminars,

ATTN: Cheri Grimm at P. 0. Box 6810, Los Osos, CA 93412 or fax to (805) 528-2581.

Questions? Call Cheri at our toll free number 800 SAM-3455 or email info@samhorn.com