The Longevity Centre

Application

	Personal Information
*Last Name:
*First Name:
*Middle Initial:
*Street Address:

*City:
*Prov./State:
*Postal/Zip Code:
*Telephone:
Fax:
*Email:
Present Occupation:
*Date of Birth:

	Education
*High School:
*Highest Grade:
*Year Completed:

College:
Degree/Diploma:
Year Completed:

Other:
Award:
Year Completed:

	References
*Name:
*Address:
*Telephone:

*Name:
*Address:
*Telephone:

*Name:
*Address:
*Telephone:

	*Program Desired (Check One)
Nutritional Awareness Certificate (Level 1)

Nutritional Counselling Diploma (Level 2)

Additional Questions or Comments:	State how you heard about the program you selected, and why you would like to take it.

	Credit Card Information A $40.00 non-refundable application fee will be processed from your credit card.
Name on the Card:
Card Number:
Exp. Date:
	I would prefer to send in a check or money order for $40.00 through the mail
	By selecting the "I accept" button below, I hereby make application for the course of instruction indicated within this form. The course of instruction is to be taught as set out in the school's catalogue, and is registered with PCTIA. If this application is accepted I agree to abide by the rules of the school.