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                                                I.A.C.A.

                        International Academy of Chiropractic Acupuncture

                               

 291 Main Road  

                                                 Holden, ME 04429

                                                 207-989-0000   Fax: 207-989-0752

                                                 www.iaca.cc


                                    Registration Form

Name:_____________________________________________

Address:___________________________Zip Code:________

Phone:_____________________________________________

Credit Card Number:__________________________________

Expiration Date:______________________________________

Amount:____________________________________________

CID: (Last 3 Digits on Back of Card)______________________

Signature:___________________________________________

E-Mail: _____________________________________________

Association Member:____Non Member:____________     Student

595.00 (3 Weeks Prior)      645.00 (3 Weeks Prior)___395.00 (3 Weeks)
615.00 (2 Weeks Prior)      665.00 (2 Weeks Prior)___415.00 (3 Weeks)
635.00 (1 Week Prior)        685.00 (1 Week Prior)___ 435.00 (3 Weeks)_
Prepay: 2400.00                2600.00                              1600.00_______


Registrations are accepted up to 90 days prior to the seminar date.
Refunds will be issued at fifty percent refund amount within two weeks of seminar date. No refunds will be issued less than seven days notice.

Mail to:
IACA
291 Main Road
Holden, ME 04429
Phone: 207-989-0000
Fax: 207-989-0752 

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