Confidential Secured Electronic Registration Form. Canadian College of Aesthetic Dermatology. BC Academy of Medical Aesthetics & Skin Care. Unit 103/2228-McAllister Avenue, Port Coquitlam, BC. Canada. V3C 2A5

Full Given and Family Name:*

Email address*

Title: Mr. / Ms. / Mrs. / Dr. / other:

Phone Number:*

Mailing address: Unit-Street #, City, Province/State, Country, Postal/zip code:*

Most Recent Education / Diploma:*

Current Occupation:*

RN, MD, ND or other License Number (if applicable):

Course(s) that you are registring for:*

Date of Course(s) you are registering for:*

Please indicate method of payment: Cash / Cheque / E-transfer / Credit card: *

Credit Card Info: Name on Card, Number, Expiry Date, 3-digit Security Code:

Print current legal Full Name (Matching with your photo ID) and Date: *

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Cancellations/Changes and Refunds: Fees will be refunded, less a $200.00 processing and cancellation fee. Cancellation note should be sent in writing no later than 7 business days prior to class start date.

Confidential Secured Electronic Registration Form. Canadian College of Aesthetic Dermatology. BC Academy of Medical Aesthetics & Skin Care. Unit 103/2228-McAllister Avenue, Port Coquitlam, BC. Canada. V3C 2A5

PRIVACY POLICY

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