International Academy of Veterinary Chiropractic
Dorfstr. 17      27419Freetz,
 GERMANY
E-mail: IAVC2004@hotmail.com
Tel: (0049) 4282 590099
Fax: (0049)4282591852 

Course / Module Registration

 Basic Veterinary Chiropractic Course

  Loughborough, England (East Midlands)

 Please print clearly  

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Title Family/ Last name                          First name                   Date of birth

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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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Veterinary or 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 register for (please checkmark):

О Single Module: Module I: (Sacropelvic, April 15th – 19th ,2009)
О Entire course prepaid beginning:
   (Module I: April 1rst- 5th, 09; Module II: May 13th -17th,09;
    Module III: June 24th- 28th, 09; Module IV: July 29th - August 2nd, 09;
    Module V: September 9th- 13th, 09)

I intend to pay by (please checkmark):   О  Cheque.       О  Bank transfer
(Please note: an international banking surcharge may apply. Ask your banking institution).

Entire course prepaid: £4000      Single Module:  £850
Please make cheques payable to: I.A.V.C., c/o Dr. Donald Moffatt.
Please send bank transfers to: I.A.V.C., c/o Dr. Donald Moffatt.
Sparkasse Rotenburg-Bremervörde, Am Markt 10, 27419 Zeven
BLZ (branch #): 24151235, Account #: 28169332
BIC/SWIFT bank identification: BRLADE21ROB, IBAN:DE 42 24151235  28169332 

 Fees are refundable, less 20%, up to two weeks prior to start of modules.  No refunds less than two weeks prior to module start, however, fees paid can be applied to a future module.

 A copy of your degree or license to practice is required with registration:

● A copy of your current license or diploma is required with registration. The course is open to doctors of chiropractic (GCC certified) and veterinary surgeons only.

Date and Signature:..........................................................................................................

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