Registration Form

REGISTRATION FORM for Boulder April 8,9, 2005

To register, please print this form, fill in your details, enclose a check or money order in US funds, and mail to Dr. Kinowski.

Please check the time of your registration to determine the registration fee:

$210 before March 01, 2005

$230 March 01 to March 30, 2005

$250 after March 30, 2005

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ADDRESS ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ

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ZIP CODE ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ Phone (ЕЕЕЕЕЕ)ЕЕЕЕЕЕЕЕЕЕЕЕЕ

E-MAIL (Please print clearly) ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ

EMDR LEVEL ЕЕЕЕ DATE ЕЕЕЕЕЕЕЕЕЕЕЕЕЕ TRAINER ЕЕЕЕЕЕЕЕЕЕ

YOUR LICENSE OR REGISTRATION # ЕЕЕЕЕЕЕЕЕЕЕЕЕЕ StateЕЕЕЕЕ

ISSUING AGENCYЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ

» Send with check or money order to:
Krystyna Kinowski, Ph.D. 201 -1005 Cook St. Victoria, BC Canada, V8V 3Z6.

I have EMDR Level 2 and want EMDRIA credits

Can't make it? Manual, protocol, and materials are available as electronic downloads on website: www.krystynakinowski.com

Cancellation fee $80.00. Receipts can be picked up at the workshop.

I want preview materials emailed to me before the workshop
I need special accommodation. Please contact me.

» My favorite beverage at workshops is ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ.