(Please print this form)

TRICHOLOGY EDUCATIONAL PROGRAM BY CORRESPONDENCE

 Send completed form with payment to:

Payment can be made by Bank Cheque, Amex, Visa or MasterCard.

Name ______________________________________________________

Postal Address  _____________________________________________
___________________________________________________________
____________________________ State____________ Postcode ______
Country       ________________________________________________

Telephone      ( ___ )  ________________________

FAX: _________________________    E-Mail: ____________________

I am enclosing a Bank Cheque for 

$ 2,200.00  for the entire trichology program 

$ 550 for the 1st instalment for the trichology program 

made payable to the "International Association of Trichologists".

I hereby authorise payment of      

$ 2,200.00  for the entire trichology program 

$ 550 for the 1st instalment for the trichology program 

Type of Card (Please tick)      Amex   Visa   MasterCard

Card number ____________________________________

Expiry ___/___

Name on Card ________________________________________________

Signature ___________________________

Date ________

 

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