Homeopathic College of Canada
Introductory, Certificate, Detoxification and Rejuvenation 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:
Detoxification and Rejuvenation Course [Internet] $7,500.00
One year Homeopathic Certificate Course [Internet] $2,500.00
Introductory Course [Internet] $495.00
 
 
 
 
 
Visa: Card #: _____________________________________ Expiry Date: ____________  
Cardholders Name: ____________________________
Date: _________________
Cardholders Signature: ___________________________________________________
____________________________________ ________________
Signature Date