Registration Information
Name: _____________________________________________
(Please print your name clearly as you would like it to appear on your certificate)
Profession: __________________________________
Address: __________________________________ City: __________________________________
Province / State: _____________________ Postal or Zip Code: _____________________
Country: ___________________________________
Phone: __________________________________ Fax: __________________________________
Email: __________________________________
Cheque #: ________________ (payable to Alta-Med please)
Credit card number #: __________________________________ Expiry Date:______________
Card type: VISA, MasterCard (circle one)
Name as shown on card: __________________________________
Signature: __________________________________
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$500 CAD deposit reserves your seat and special registration rate (balance due one month before course date)
Please check one:
_____ Toronto, Ontario, Canada — October 2, 3, 2010 Level One: REGULAR PRICE $3,999.00 CAD.
Registration Special $2,899.00 CAD. Registration special deadline is August 16, 2010 (First 5 Registrants receive $2,299.00 CAD rate)
_____ Toronto, Ontario, Canada — October 1, 2, 3, 2010 Level One: REGULAR PRICE $1,999.00 CAD.
Registration Special $1,699.00 CAD. Registration special deadline is August 16, 2010 (First 5 Registrants receive $1,499.00 CAD rate)
1) Please register me for Level One $500 CAD deposit reserves my seat. Registration special $2,899.00 CAD (+applicable taxes) ______
2) Please register me for Level Two $500 CAD deposit reserves my seat. Registration Special $1,699.00 CAD (+applicable taxes) ______
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(I have completed Level One) Date of Completion:__________________________________
3) ______ I wish to reserve an Accu-O-Matic microcurrent machine for purchase.
$200 deposit required, balance due two weeks before the course. Regular Price $4,000 CDN , Course special $3,500 CDN (+ applicable taxes & shipping) Save $500
______ I wish to purchase an Accu-O-Matic microcurrent machine for immediate shipping.
Regular Price $4,000 CDN , Course special $3,500 CDN (+ applicable taxes & shipping) Save $500
4) How did you hear about this event?
Website ______ Email ______ Referred by ______ Phone number of Referrer:____________________________
Other __________________________________
4) If you have a PROMOTION CODE, please enter it below
____________________________________
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Fax or mail registrations to:
ALTA-MED, PO Box 2003, RMH, AB. T4T 1B5
Fax 403-845-7223, Phone 1-800-892-9023
email: secondchance@hughes.net
Cancellation policy: Full refund if you need to cancel up to
30 days prior to course date, thereafter your full
course fee will be applied to an upcoming event of your choice.
We reserve the right to cancel courses if required