Name....................................................................................................

Address................................................................................................

.........................................................................Post Code....................

Tel.(H) (........) .................................... (W) (.........) ..............................

I heard about the College through..........................................................

............................................................................................................

Please find enclosed my: Cheque Money Order Credit card details

Please make cheques payable to:
The Australian College of Chi-Reflexology

I hereby acknowledge that I have read, understand and agree to abide by
all rules, Regulations, and Conditions as set by the Australian College
of Chi-Reflexology.

Signature......................................................................

Date........./.........../...............

Mail to: The Principal
Australian College of Chi-Reflexology
P.O. Box 4071, Winmalee N.S.W. 2777

Or fax with credit card details to:
02 4754 5588

Course Required: (Please indicate Course/s with a tick)

General Interest Course

Reflexology I Weekend or Monday please circle

Reflexology II Weekend or Monday please circle

Reflexology III and Diploma of Clinical Reflexology Modules

Chi-Reflexology III and Diploma of Chi-Reflexology Modules

Anatomy & Physiology 1

Anatomy & Physiology 2

Diploma Clinical Reflexology/Chi-Reflexology Modules

Diploma of Reflexology (Medical) Modules

Post Graduate Course

Please Note:

*Full payment of $220.00 including GST is required to secure a place
in Reflexology I.

* a deposit of $55.00 including GST is required to secure a place for
all other Courses. This deposit will be deducted from the last Workshop of Course of Study, OR from the last amount due as applicable.

* For Credit Card payments, there is a 5% added charge

For credit card payments please fill out below.

Card Type :  

VISA     Mastercard     Bankcard    (These cards only accepted)

Card Number :  

Expiry Date :  

Name on Card :  

Address of Name on Card :

Contact Telephone :  


Please Note: Your signature and the date section must be completed for all applications.