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
Space reserved
for the KJcÕs Security Office. Do not
write in this space below.
REGISTRATION NO. _____________
DATE: KJCÕs EAGLE CREATIONS© Enginering and
Communicative Arts