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.

   Name : ________________________________________

   Organization: _______________________________________

   Address:__________________________________________________________________________

   City: _______________________ Province:_________________ Postal: _____________________

   Home Phone: __________________ Bus. Phone:__________________Fax: _________________

   Email: _______________________________________

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

   Signature: _____________________________________ Date: ____________________________

   Mail completed form and cheque to:

If you prefer to pay by VISA, please complete the following:

VISA #__________________________________Expiry____________________

Signature:________________________________________________________