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.
	Name as it should appear on your certificate (including title and/or degrees)*
Contact Information
	Street Address*(include business name if applicable)
	City*
	State/Province* (if applicable)
	Postal Code*
	Country*
	Home Phone Number*	( )
	Cell Phone Number	( )
	Work Phone Number	( )
	Email Address*
Co-Attendee's Name (if registering as a couple)
	Name as it should appear on your certificate (including title and/or degrees)
	If contact information is different than primary address/phone above:
	Street Address
	City
	State/Province
	Postal Code
	Country
	Home Phone Number	( )
	Cell Phone Number	( )
	Work Phone Number	( )
	Email Address
Monday Workshop (free for registered attendees)
	I (we) will be attending:*	Select... Yes No
Payment Information
	Method of Payment*	Select... Check / Money Order VISA / MasterCard / Discover / AmEx
	Registration Type*	Select... Early Bird - $295 Early Bird Couple - $495 Regular - $345 Couples - $595
	Name on Credit Card
	Credit Card Number
	Card Verification Number	What is this?
	Expiration Date	/
	I am a current ICI Member*	Select... Yes No A $25 discount will be applied for current members.
• 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).