I would like to apply for the following course starting:

Please specify your 1st choice and 2nd choice

______ January – application is due November 15th .............................$6,500.00

______May – application is due March 15th .........................................$6,500.00

______September – application is due July 15th ....................................$6,500.00

Name:__________________________________________ Date of Birth: (Y/M/D)___________________

Address:
Street/ RR/P.O. Box ___________________________________________________________________

City_________________________________________ Postal Code________________________

E-Mail_________________________________________ Phone___________________________

Do you have any health problems or disabilities that might affect your safety in this program?
_____ No

_____ Yes – Please Explain:_______________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________

Please include or forward the following;

• One or two charachter references from professional sources
• A letter from you , stating why you are interested in taking this course.