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REGISTRATION FORM - Mediation and Domestic Violence

   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 Mediation and Domestic Violence Program:

   Name : ________________________________ Occupation: _______________________________

   Address:__________________________________________________________________________

   City: _______________________ Province:_________________ Postal: _____________________

   Email: ___________________________________________________________________________

   Home Phone: __________________ Bus. Phone:__________________Fax: _________________



   If payment by VISA Mastercard, please complete:

   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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