Course Name: _________________________________Date:__________________

Course Cost ___________ Form Payment______________ Cheq ____ Cash ____

Personal Information:

Name: ____________________________________Address ____________________________

City: ______________________________________ Postal Code __________________________

Phone: _____________________________________ Fax: _________________________________

e-mail address: ______________________________________________________________________

Additional Information:

Other Continuing education courses you would like to see offered:

___________________________________________________________________________________

___________________________________________________________________________________

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