| Name Date: |
| Address |
| City Postal Code |
| Home Phone Work Phone |
| Fax # E-mail |
| Date of Birth Occupation |
| Related Experience |
| Education |
| Diplomas/Certificates |
| Qualifications |
| I wish to pay by (X) Canadian Funds Only |
| ( ) Debit ( ) Cheque ( ) Master Card ( ) Visa ( ) Am Express ( |
| Card # Expiry Date |
| Signature: |
Please write which course you are signing up for and the cost of each course.
Enrollment Contract - Terms and Conditions
Declaration:
I ________________________________________ accept the terms and conditions above and wish to register for The Canadian Institute of Alternative Medicine &/or Heaven Scent Program as marked above. My personal information is correct and I have included copies of the necessary diplomas. Date _________________________Signature__________________________________
Send or deliver registration form to:Heaven Scent 169 Wortley Road London, Ontario N6C 3P6 Credit card number attached or cheque to accompany registration payable to Christine Richards._____________________________________________________________________