Registration Form for Introductory and Certificate Programs in Homeopathy

Homeopathic College of Canada

Introductory and Certificate Programs in Homeopathy

Registration Form

	______________________		______________________		______________________
	Last Name		First Name		Middle Name

Dr. ___

Mr. ___

Ms. ___

Mrs. ____

E-mail: ____________________________

	__________________________________________________		______________________
	Permanent Address (Street & Number)		City

	_______________________		______________________		______________________
	Province/State		Postal Code/Zip Code		Country

	_______________________		______________________		______________________
	Home Telephone		Business Telephone		Fax

Previous Education:

		_______________________________________________________________________________

	_______________________________________________________________________________


I would like to enroll in:
One year Homeopathic Certificate Course [Classroom]	$2,500.00
One year Homeopathic Certificate Course [Internet]	$2,500.00
Introductory Course [Classroom]		$495.00
Introductory Course [Classroom]
Introductory Course [Internet]
		$495.00

Cheque enclosed [payable to "HCC Homeopathic Inc."

Visa:	Card #: _____________________________________	Expiry Date: ____________

	Cardholders Name: ____________________________	Date: _________________

	Cardholders Signature: ___________________________________________________

I hereby certify that all statements on the application and any material filed in support are true, correct and complete and all necessary information has been disclosed.

____________________________________

________________

Signature

Date