ࡱ> @B?M Objbj== & WWlJJJJJJJ~ ~W&2%%%%%%%$' )%EJ% JJ& RJJ% %  #JJ% 5^6~4) :$%'&0W&$S*c ^S*% ^pJJJJ AUTHOR WORKSHOP REGISTRATION FORM It is recommended, regardless of preferred payment method, that this form be printed, completed, and total fees sent by regular mail. Contact Information First Name Last Name ________________________________________ _______________________________________ Street Address: (please provide as complete an address as possible) _____________________________________________________________________________________ City/Town Province/State ________________________________________ _______________________________________ Postal/Zip Code Daytime Phone: ________________________________________ _______________________________________ Evening Phone Fax Number and/or e-mail address ________________________________________ _______________________________________ Workshop Information Indicate your workshop selection(s) by checking (() the appropriate box(es). o Breast Massage November 8 & 9, Toronto, Canada Instructors: Debra Curties, Pam Fitch Please indicate costs where applicable Within Canada Regular fee: $275 CDN (after Oct 01, 2003) _____ Early fee: $ 235 CDN (before Oct. 01, 2003) _____ Mandatory text: ($47.95 + $3.36 GST) _____ TOTAL _____ From the United States Regular fee: $200 USD (after Oct 01, 2003) _____ Early fee: $ 160 USD (before Oct 01, 2003) _____ Mandatory text: ($36.95) _____ TOTAL _____ Method of Payment Indicate your preferred payment method by checking (() the appropriate box. If you are paying by credit card and intend to submit this information via e-mail, for security reasons, two separate e-mails are recommended: one indicating the card number, and the next one indicating the expiry date. Within Canada: oMoney Order oCheque oVISA Card # ______________________________ Expiry Date _______ Signature ________________________________________________ From the U.S.: oMoney Order oCheque oVISA oMasterCard Card # ______________________________ Expiry Date _______ Signature ________________________________________________  HYPERLINK "mailto:copi@sutherland-chan.com" Click here to submit by E-Mail Submit by regular mail to: Curties-Overzet Publications 330 Dupont Street, 4th Floor Toronto, Ontario M5R 1V9 Attn: Tanya-Lynn Paul #$=q_8LM  $ R z   5 L c w , - E B D ` b d ~ svwO0JjU jU 56\]565OJQJ j6]mH sH 6]>*5\ 5>*\J#$,-qr9:^_78MN$a$ON"d  $ & " 4 5 L M ~ B D $a$  9tuv7MNOh^h$a$ p^p` ^`$&P1F/ N!"#$%DyK yK @mailto:copi@sutherland-chan.com i8@8 NormalCJ_HaJmH sH tH 2@2 Heading 1$@&5\<A@< Default Paragraph Font.U@. Hyperlink >*B*ph>V@> FollowedHyperlink >*B* ph  @V#$,-qr9:^_78MN ./`Mn%`abe000000000000000000000000000000000000000000000000000000000000000000000000O N O O A`X8@0(  B S  ?:^/68:]L:NFMfhnNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazilapC:\Documents and Settings\Administrator\Desktop\grad on Compaq Evo Igor (Igor)\Webpage\Webpage 1\workshopreg.docNazila Mohammadi M:\Web Page\copi\workshopreg.docIcS jR{{c&{91O:M4{pIJ ,xh^`CJOJQJo(qh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`CJOJQJo(qh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`CJOJQJo(qh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`CJOJQJo(qh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h^`CJOJQJo(qh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h 88^8`OJQJo(h ^`OJQJo(oh   ^ `OJQJo(h   ^ `OJQJo(h xx^x`OJQJo(oh HH^H`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(91pIIcS c&M4{,x                                                               @//,&/.@P@PP@P P@UnknownGz Times New Roman5Symbol3& z Arial;Wingdings?5 z Courier New"1h3vvv !x0d 2Q!AUTHOR WORKSHOP REGISTRATION FORMSandra Di NardoNazila MohammadiOh+'0 4@ \ h t "AUTHOR WORKSHOP REGISTRATION FORMosUTHSandra Di NardoandandNormalDNazila MohammadiEGI5ziMicrosoft Word 9.0I@vA@A]6@Z,@B^6՜.+,D՜.+,l( hp  !Curties-Overzet Publishing, Inc.d  "AUTHOR WORKSHOP REGISTRATION FORM Title 8@ _PID_HLINKSAxd mailto:copi@sutherland-chan.com  !"#$%&'()*+,-.012345689:;<=>ARoot Entry F5^6CData 1TableS*WordDocument& SummaryInformation(/DocumentSummaryInformation87CompObjjObjectPool5^65^6  FMicrosoft Word Document MSWordDocWord.Document.89q