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.

PLEASE ENTER YOUR NAME EXACTLY AS YOU WOULD LIKE IT TO APPEAR ON YOUR CERTIFICATE, INCLUDING FORMAL DEGREES AND DESIGNATIONS.

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):	/ /

I found out about this course through:
	ADR Institute

	Conrad Grebel School
	Other University
	Through Work
	A Friend or Colleague
	A Publication Please Specify:

**NOTE: Registration cut off is 14 business days prior to course start date.
Any registrations received after that time will be subject to an additional $50 administration fee.
* A 5% discount applies to those registrations, with payment, received 30 days in advance.

* Cancellations: Written notice required. Prior to 8 days before course starts: Refund less $160.00 Administrative Fee. Within 7 days before course starts: No refund.

* As required by the Mediation Associations, the full course must be completed within one year.

Deferral to a later course: Written notice required. Prior to 14 days before course starts: No Administrative Fee. 8 to 14 days before course starts: $80.00 Administrative Fee. Within 7 days before course starts: $160.00 Administrative Fee. Substitution of registrant is permitted.

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:

Mary-Anne Popescu at Cooperative Solutions
Phone: (416) 481-3651
Phone toll-free 1 (888) 595-5534
Fax: 416-391-2347
mpopescu@coop-solutions.ca

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