Canadian International Institute of Applied Negotiation

Registration Form

ADR Certificate Program & Modules I, II, and III

Register today: (1) Online;  (2) By Mail;  (3) By Fax; or (4) By Telephone

Please address all my correspondence to my Home  or Office as follows:

NAME (Please Print)                                                                   

(As it will appear on certificates)

TITLE:

SECTION:

COMPANY/DEPT:

MAILING ADDRESS:

CITY:        

PROVINCE:                                                              POSTAL CODE:

TEL HOME:                                                               TEL WORK:

FAX:                                                               EMAIL:

How did you hear about our courses?

Have you taken CIIAN courses before?      YES             NO

Do you have any other non-CIIAN training in ADR, NEGOTIATION OR MEDIATION?

  YES             NO

If yes, please indicate where:

Registration Fee: Your registration fee covers the selected module and all course materials.

Corporate Discount Rate: A $50.00 discount per person is available when 3 or more people attend the same course from the same Organization.

Cancellation Policy: A cancellation made later than one week prior to a course will be subject to 50% of the course fee. Cancellations made earlier than one week prior to a course will be subject to a $75.00 Administration Fee.

PAYMENT OF REGISTRATION FEES

OTTAWA COURSE FEES

SELECTION (please indicate date and module choice)

*Module I

$1,800.00 + $90.00 GST = $1,890.00

Monday February 23 - Thursday Feb 26, 2009

Tuesday August 18 - Friday Aug 21, 2009

*Module II

$1,800.00 + $90.00 GST = $1,890.00

Monday March 23 - Thursday Mar 26, 2009

Monday August 24 - Thursday Aug 27, 2009

Module III

$1,950.00 + $97.50.00 GST = $2047.50

Monday October 19 - Thursday 22, 2009

Special Programs

Priced Accordingly

*Modules I & II: Completion of both Modules has been accepted as an Approved Mediation course by the ADR Institute of Ontario Inc.  All courses are approved for Federal Income Tax Deduction.  Your paid invoice is your receipt.

Payment Method

Please invoice my employer.  Billing information as follows:

Company:

Attention/Reference:

Address:

City/Province:

Postal Code:

My cheque or money order is attached (made payable to CIIAN)

Please bill by VISA or MasterCard (if registering by mail or fax). Information below.  If registering online, please fax or call with your credit card information.  For your security, do not provide credit card information online.

Cardholder Name:

Account Number:

Expiry Date:

Cardholder Signature:

If Employer is paying tuition, does the employer wish a tax receipt to be issued?

YES   NO

(Please Note:  If this question is left blank or answered "NO", no tax receipt will be issued)

Name or Organization to which the tax receipt is to be issued. (Please Note: if the Employer is paying the cost of tuition, the receipt will be issued in Employer's name only upon request by the Employer):

Registration closes two weeks prior to each course. Early registration will help ensure a place.  Please return this completed form with payment to:

CIIAN, 320 Laurier Avenue East, Ottawa, ON K1N 6P6

CIIAN Domestic Training Program, 320 Laurier Avenue East, Ottawa, Ontario  K1N 6P6
Tel: (613) 237-9050 Fax: (613) 237-6952

Email: ciian@ciian.org

Website: www.ciian.org