The information on this form and any correspondence between us, will be treated with care, sensitively, confidentially and privately.
I would like a place on the: Acu-Stim Skills Course
Name: ...............................................................................................................
Birth Date:.................... & Home post code....................................................
Job Title:...........................................................................................................
Organization: ...................................................................................................
(Name, address.................................................................................................
& Contact details.)............................................................................................
Invoice Contact:................................................................................................
Telephone:.........................................................................................................
Email:................................................................................................................
Home address: .................................................................................................
Telephone:.........................................................................................................
Email:................................................................................................................
Dates of course:
(Preferred month/year)...................................................................................
Main interest in attending course:.................................................................
...........................................................................................................................
.
Details of any disabilities / special requirements (physical, visual, hearing, learning etc
..........................................................................................................................
..........................................................................................................................
Please return completed Request form by:
Email: blackbox@acustimtraining.co.uk