APPLICATION FORM

Homeopathic Institute of North America

389 Main St. North of (suite:218)

Brampton, Ontario, Canada L6X 3P1

Tel: (905) 456-9090

Fax: (905) 456-9294

Please use BLOCK capitals Dr/Mr/Ms/Mrs. (circle one) Date:___________________

Last name:____________________________________________

First name(s):__________________________________________

SIN number (If Applicable):______________________________

Date of Birth:_________________________

Address:______________________________________________

______________________________________________________

______________________________________________________

Telephone # with area code:______________________________

Alternate#:______________________________

Fax or E-mail:__________________________________________

Qualifications:__________________________________________

______________________________________________________

(please attach photocopy(s) of your certificates with the application)

Have you ever committed a criminal offense for which no pardon has been issued:

_______________________________________________________

Signature:____________________________________

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Course selected: (Circle one)

1.Correspondence    2.Three year full time     3.Three year part time    4. Other

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Email: Hinahomeopaths@yahoo.com

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