EMS Registration

Thank you for trusting us to help you restore your marriage. After registration you will receive more information such as directions and payment options. Please keep in mind that your reservation will not be secure until a deposit has been received.

If you have any questions please use the contact form

Your registration will not be complete without submitting a deposit of $500. You will be redirected to the payment page after hitting submit

Which seminar weekend would you like to attend?: * - Select -January 13-15, 2012 in Austin, TexasFebruary 10-12, 2012 in Austin, TexasMarch 9-11, 2012 in Austin, TX

Husband Information

What is the husband's first name?: *

Be sure to add your "nametag" name if different (i.e. Michael "Mike")

What is the husband's last name?: *

What is the husband's email address?: *

cannot be the same as wife's

What is a good phone number to reach the husband?: *

Please use this format: 000-000-0000

This phone is a...: * Cell PhoneHome numberWork numberOther

Wife Information

What is the wife's first name?: *

Be sure to add your "nametag" name if different (i.e. Jennifer "Jenny")

what is the wife's last name?: *

What is the wife's email address?: *

cannot be the same as husband's

What is a good phone number to reach the wife?: *

Please use this format: 000-000-0000

This phone is a...: * Cell PhoneHome numberWork numberOther

City: *

State: * - Select -ALAKASAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Which spouse has been unfaithful?: * - Select -husbandwifebothneither

Which spouse are you? : * - Select -I am the wifeI am the husband

How did you hear about AR?: * - Select -PastorFriendTherapistNewsletterWeb search GoogleWeb search MSNWeb search YahooWeb search otherNot listed

If you would like, you can tell us a little of your story.: This question is optional

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