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Registration Form

To register, please complete the form below then select 'Submit' to email it directly to our office,
or select 'Print This Form' from the top of this window to mail or fax the form to our office.
 Please enclose a cheque made payable to Dr. Barbara Landau.

If preferred payment is by credit card, please complete the additional information on the form before submitting.

If printing, please include your signature before faxing or mailing the form.
Please print clearly and keep a copy for your records.

Tax receipts will be issued.
Name:
   * Degree:    
Employer:
  Profession:    
Address:    *
   
City:  *
Province:
*
Postal Code:
 *
Home Phone:  *
Business Phone:
Fax:
Additional Phone:
Email Address:

Please enroll me in the following program:
 *

Payment method:   Cheque Visa Mastercard *
       
If payment by credit card, please fill in the following:
 
Account Number:  
 
Expiry Date (mm/yy):   /
 
Signature:  ______________________________________
 
Today's Date (mm/dd/yy):   /   /  

   * 5% discount for payment in full received 30 days prior to the course start date.
   * Refunds less $160.00 administration fee for written notice of withdrawal up to 14 days prior to course start date.
   * As required by the Mediation Associations, the full course must be completed within one year.

**NOTE:   Registration cut off is 10 business days prior to course start date.   Any registrations received after that time will be subject to an additional $50 administration fee.
Mail completed Registration form &
cheque payable to "Dr. Barbara Landau" to:

 Cooperative Solutions Inc.
76 Truman Road
Toronto, Ontario M2L 2L6
Canada		 For more information:

Carol Seglins at Cooperative Solutions
Phone: (416) 481-3651
Phone toll-free 1 (888) 595-5534
Fax: 416-391-2347
 

 

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