Please complete the following form and click the Submit button at the bottom of the page to send your application to The International College of Iridology. If you have any questions regarding the application, please call 1-888-573-EYES [3937] or send an email to info@iridologycollege.org.

(* - indicates a required field)

Name
	Title	Select... Mr. Mrs. Ms. Dr. Rev. Prof.
	First*
	M.I.
	Last*
	Degree, etc.
	Names as is should appear in the online directory:
Contact Information
	Business Name (if applicable)
	Street Address*
	City*
	State/Province* (if applicable)
	Postal Code*
	Country*
	Home Phone Number*	( )
	Cell Phone Number	( )
	Work Phone Number	( )
	Fax Number	( )
	Email Address*
	Website
Additional Information
	Select... Less than 2 years Two to five years More than five years Please indicate your general level of knowledge and use of iridology.*
	Briefly describe your experience with iridology, including the courses (and dates) you have taken and the names of the instructors.*
	Modalities offered in your healthcare practice:
	Select... Yes No Do you use iris photography? If yes, 35mm or Digital? Select... 35mm Digital If Digital, name of system:
	Select... Yes No Do you prefer to be a member of the Spanish speaking chapter of ICI?*
Payment Information - ICI Membership ($75 per year)
	Method of Payment*	Select... Check / Money Order VISA / MasterCard / Discover / AmEx
	Name on Credit Card
	Credit Card Number
	Card Verification Number	What is this?
	Expiration Date	/
• Make check or money order payable to: David J. Pesek • Mail check or money order to: 375 Paradise Lane, Waynesville, NC 28785 • Charge will appear on credit card statement as Center for Effective Living Yes Yes No Please add me to your private mailing list (we do not share or sell lists).