The Institute (North America) of Biochemic Medicine Inc.
STUDENT ENROLMENT APPLICATION and Book order form
Name: ………………………………………………………………….
Address: ………………………………………………………………
Postal code………………….. Country…………………………..
E-mail:…………………………………………………………………..
Telephone :…………………………………………………………..
Facsimile :…………………………………………………………….
Date of Birth: ………………………………………………………..
Occupation……………………………………………………………
Qualifications………………………………………………………..
Please enrol me as a student in the :
Biochemic Medicine Course (Dr med W.H.Schuessler)
Description QTY Total
Biochemic Diploma Course _____ x * ________
Biochemic Facial Diagnostics _____ x * ________
Guide to the Biochemic Health Therapies of Dr.(med) W.H. Schuessler
_____ x * ________
Magnesium an Essential Element of Life
A Guide to Biochemic Nutrition ______ x * ________
“WAY TO GOOD HEALTH “ - (6 issues) _____ x * ________
TOTAL (CAD/USA*) …………………………………………………… _______________
*All Registrations outside of the Canada will be billed in Canadian currency.
PayPal mitchm@telus.net
Please charge my credit card : VISA
Number…………………………………………………………Expiry date…………………………….
Name shown on Card…………………………………………………………………………….
Signature………………………………………………………………………………
(Information and Address need to match billing address)
Email registration to info@biochemiccellsalts.com or fax to 1 604 597 8335.
Highlight yellow area, copy and paste in email body to info@biochemiccellsalts.com.
All courses registered outside of Canada will be Posted at Canadian Currency.