Course Registration Form for Modules I to IV by DI0rR5B


									             Canadian International Institute of Applied Negotiation

                                  Registration Form
                    ADR Certificate Program & Modules I, II, and III

        REGISTER TODAY:       (1) Online; (2) By Mail; (3) By Fax; or (4) By Telephone

Please address all my correspondence to my  Home or  Office as follows:

NAME (Please Print)                                                    (As it will appear on certificates)





CITY:                            PROVINCE:                              CODE:

TEL HOME:                                             TEL WORK:

FAX:                                          EMAIL:

How did you hear about our courses?

Have you taken CIIAN courses before?           YES           NO

Do you have any other non-CIIAN training in ADR, NEGOTIATION OR MEDIATION?
 YES            NO
If yes, please indicate where:

Registration Fee: Your registration fee covers the selected module and all course materials.

Corporate Discount Rate: A $50.00 discount per person is available when 3 or more people attend
the same course from the same Organization.

Cancellation Policy: A cancellation made later than one week prior to a course will be subject to
50% of the course fee. Cancellations made earlier than one week prior to a course will be subject to
a $75.00 Administration Fee.

         Domestic Training Program, 280 Albert Street, Suite 201, Ottawa, Ontario, Canada K1P 5G8
                     Tel: (613) 230-0373 Toll Free: 1-866-212-8022 Fax: (613)238-3340

                        Email:  Website:

                              PAYMENT OF REGISTRATION FEES
                         OTTAWA COURSE FEES                                        (please indicate
                                                                                  date and module
                       $1,800.00 + $108.00 GST =       March 20-23, 2007
   *Module I
                                        $1,908.00      August 14-17, 2007
                       $1,800.00 + $126.00 GST =       March 26-29, 2007
   *Module II
                                        $1,926.00      August 20-23, 2007
                      $1,950.00 + $136.50.00 GST       October 16-18, 2006
   Module III
                                      = $2,086.50      October 22-24, 2007
                                 Priced Accordingly
*Modules I & II: Completion of both Modules has been accepted as an Approved Mediation course by the
ADR Institute of Ontario Inc. All courses are approved for Federal Income Tax Deduction. Your paid
invoice is your receipt.

                                         Payment Method

 Please invoice my employer. Billing information as follows:
                 City/Province:                                          Postal Code:
 My cheque or money order is attached (made payable to CIIAN or MDR Associates)
 Please bill by VISA or MasterCard (if registering by mail or fax). Information below. If
registering online, please fax or call with your credit card information. For your security, do
not provide credit card information online.
                 Cardholder Name:
                 Account Number:
                 Expiry Date:
If Employer is paying tuition, does the employer wish a tax receipt to be issued?  YES  NO
(Please Note: If this question is left blank or answered “NO”, no tax receipt will be issued)
Name or Organization to which the tax receipt is to be issued. (Please Note: if the Employer is
paying the cost of tuition, the receipt will be issued in Employer’s name only upon request by the

Registration closes two weeks prior to each course. Early registration will help ensure a place.
Please return this completed form with payment to:

                CIIAN/MDR Associates, 201-280 Albert St, Ottawa, ON K1P 5G8

          Domestic Training Program, 201-280 Albert Street, Ottawa, Ontario, Canada K1P 5G8
                   Tel: (613) 230-8671 Toll Free: 1-866-212-8022 Fax: (613)238-3340

                       Email:  Website:

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