ETHNOMEDICINE

APPLICATION FORM

Course code: ETMED21

 

 

 
Name                                                                                                                                                                                  Photo

 

 

 

 

 
Place and Day of Birth                                                                                                dd.mm.yyy

 

 

 
Country

 

 

 
State

 

 

 
e-mail

 

Here I say that the data above are correct and correspond to the truth.

 

I am aware of the content of the course and the intended goal.

The payment of the fee of Û 270.00 is entitled to Registration, and will not be reimbursed in case of rethinking of the interested party for any reason. I undertake to pay the monthly installments (Û 90,00) as indicated in the table published on the official link-website https://www.johanchantney.org/ethnomedicine.html

I am also aware that failure to pay the monthly fees excludes me from participating at the course with the obligation to pay the full fee of Û 990.00 by 22 November 2021.

- Copy of the payment for Registration, attached here by e-mail_

 

I, with the ability to understand and want, without any constraint, here I intend to ask to be enrolled/Registration at the Course of EthnoMedicine 2021, respecting the procedures described in the attachment to this document.

Your data entered are intended for internal use only and will never be disclosed.

Yes, I want to receive the Invoice/Bill. – No, I donÕt want to receive the Invoice/Bill.

If  ÒYesÓ, please send e-mail at eagle@johanchantney.org  with billing data and copy of ID Card or Passport.

 

e-Signature or Phone number

 

 

  __   March 2021

 
Today

 

 

 

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