Dr. Mr. Mrs. Ms.        E-mail:

          
Permanent Address (Street & Number)              City

     
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Home Telepone                      Business Telephone                 Fax

Previous Education (please provide brief description of previous education)


I would like to register for the following Homeopathy Course:
Introductory Course - Correspondence ($ 495.00)
Introductory Course - Classroom ($ 495.00)
Homeopathic Certificate Course - Correspondence ($2,500.00)
Homeopathic Certificate Course - Classroom ($2,500.00)

Please choose a method of Payment:
I will pay through an online secure form - SSL encryption page.
       (only VISA is accepted at this time)
I will phone in my credit card info to 416-481-8816 or 1-888-DR-HOMEO
       (only VISA is accepted at this time)
I will mail a cheque payable to "HCC Homeopathic Inc."