Lost Certificate

Please complete and submit the following form if you have lost your certificate, and would like a replacement sent to you.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Phone Number:
Fax Number:
Email:

Which certificate did you lose?
When did you take the course?

How would you like to receive your replacement certificate?	Mail Email Fax

Comments:	Enter comments here!
Enter code to the right, then submit *

Please mail $5 to:

Empowering People
12402 N. Division #291
Spokane, WA 99218

Once funds are received, certificate will be sent.