CCHM Registration

Title *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Preferred way to contact *

Phone

Any

Have you applied with CCHM before? *

Yes

If "yes" why were you not admitted?

Current Profession *

Reference/Educator/Mentor(s)

Please upload all scanned documents here

Name of desired program *

Eclectic Medicine ($800.00)

Humanitarian & Civility $1,33.33 (1/3 Instalment)

Humanitarian & Civility $4,000.00 (Full)

Naturotherapy ($600.00) per subject

Orthomolecular Nutrition ($600.00) per subject

Professional Development ($800.00) per certificate

Sub course *

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Is your billing address the different from your residing address? If "yes" please fill the form below *

Yes