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REGISTRATION FORM - ADVANCED MEDIATION SKILLS

To register, please enclose a cheque made out to Dr. Barbara Landau. If you prefer to pay by credit card, please indicate account #, expiry date and signature in the space provided.
Tax receipts will be issued.
Please print clearly and keep a copy for your records.

Please enroll me in the following Advanced Mediation Skills Program:

Date of program__________________ City ___________________

   I am enclosing a cheque in the amount of $1,385.65 (including GST) made payable to Dr. Barbara Landau.

   * 5% discount for payment in full received 30 days prior to the course start date.
   * Refunds less $150.00 administration fee for written notice of withdrawal up to 14 days prior to course start date.

Name : ________________________________ Occupation: _______________________________

Address:__________________________________________________________________________

City: _______________________ Province:_________________ Postal: _____________________

Home Phone: __________________ Bus. Phone:__________________Fax: _________________

Prerequisite course:

Offered by: _____________________________ Date Completed: __________________________

Account # _________________________________ Expiry Date: _____/_____/_____ (mm/dd/yy)

Signature: _____________________________________ Date: ____________________________

Mail completed form and cheque to:

Dr. Barbara Landau
76 Truman Road
Toronto, Ontario M2L 2L6
Canada

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