*Email Address:

Title:

*First Name:

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Clinic Name:

*Telephone:

Mobile Number:

Fax Number:

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*Suburb:

*County/State:

Post Code:

*Country: United Kingdom Ireland France United States Canada Australia Singapore Hong Kong New Zealand N/A

*CDI Course: The Neurology of Chiropractic (CTCP Mod 1 in London on 13-14 November 2010)

*Fee Category: Standard Fee AUD $900 Early Bird Fee AUD $800 (must be paid 6 wks before event) Student Fee AUD $600 Student Early Bird Fee AUD $500 (must be paid 6 wks before event)

*Card Type: VISA MasterCard

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*Expiry Month: 01 02 03 04 05 06 07 08 09 10 11 12

*Expiry Year: 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Special Requirements:

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*Required