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International Academy ofVeterinary Chiropractic
Dorfstr. 17 27419 Freetz,
GERMANY
E-mail: iavc2004@hotmail.com
Tel: (0049) 4282 590099
Fax: (0049)4282591852
Course / Module Registration
Advanced Animal Chiropractic Course
in Sittensen, Northern Germany
(Please print clearly)
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Title Family/ Last name First name
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Post address Country
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Phone Mobile Fax
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E-mail Profession (Vet, D.C.) / further degrees
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Basic Animal Chiropractic training at (school attended). Date of completion
We prefer E-mail as the main form of contact. If you prefer another means, please indicate how we should alternatively contact you: О Mail О Fax
Course / Module Fees: I intend to pay for (please checkmark):
О 495 € Applied Kineosology Technique
О 525 € Advanced Module 3 Cervical
О 950 € Applied Kineosology Technique & Advanced Module 3 Cervical
I intend to pay by (please checkmark): О Bank transfere О Cheque О Cash
Fees are refundable, less 20%, up to two weeks prior to start of modules. No refunds less than two weeks prior to module start, but fees paid can be applied to a future module.
Please make bank transfers and Cheques payable to:
International Academy of Veterinary Chiropractic (IAVC), Dr. Donald Moffatt:
Branch (BLZ): 24151235 Sparkasse Rotenburg-Bremervörde. Account No. 28005338
BIC (SWIFT) Code: BRLADE21ROB (IBAN)Code: DE 24241512350028005338
Date and Signature:
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