REGISTRATION FORM

I wish to attend the
which will run between :

Name .................................................................................................Male......Female (please circle)
Organisation/Company...................................................................................................................
Address.........................................................................................................................................
.......................................................................................................................................................
State..................... Postcode .................................. Country........................................................
Phone ........................................................(ah) Phone........................................................... (bh)
Mobile........................................................ Fax...............................................................................
Email................................................................................................................................................
Occupation.....................................................................................................................................
Food Preferences: Vegetarian .........Meat — I do eat Beef.....Chicken.......Fish....... (please circle)
Special Dietary Requirements ........................................................................................................
........................................................................................................................................................
Payment Details
Credit Card Payments
Please note that credit card payments attract a 3.95% bank surcharge
and are processed by our sister organisation, the Global Ecovillage Network.
If paying by credit card do NOT send this form back via email. Please either fax it to us or post it.

Credit Card Type: Bankcard / Mastercard / Visa – (please circle one) No AMEX or Diners, sorry!

Name (as it appears on the credit card): ......................................................................................

Card Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiry Date: _____/_____

I enclose a deposit of AUD$500 — Cheque / Money Order / Credit Card (please circle one)
Please make cheques payable to ECOLOGICAL SOLUTIONS
Deposit Policy
While the deposit is not refundable, if you cancel before 2 months of the course start date, you can transfer it to another course offered by EcoLogical Solutions (except the EcoLogical Solutions University and Customised Programmes). In the unlikely event that the course is cancelled by us, your full deposit will be returned.

I understand that the balance owed is due on the first day of the programme.

Signature:............................................................................... Date:................................................

Please send form, with your deposit payment, to:
EcoLogical Solutions,
59 Crystal Waters, 65 Kilcoy Lane,
Conondale Qld 4552, Australia
Fax: (07) 5494 4578 (International: +61 7 5494 4578).