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
Banquet Information
	I will be attending:*	Select... Yes - $29 No | Co-attendee:* Select... Yes - $29 No
	Your Choice of Entrée*	Select... Breast of Free-range Chicken Seared Atlantic Salmon Vegetarian/Vegan Penne Pasta (Feta Cheese on the side)
	Co-Attendee's Choice of Entrée*	Select... Breast of Free-range Chicken Seared Atlantic Salmon Vegetarian/Vegan Penne Pasta (Feta Cheese on the side)
Monday Workshop
	I (we) will be attending:*	Select... No Bach Flower Workshop - $95 Face Analysis Workshop - $95
Payment Options
	Method of Payment*	Select... Check / Money Order Credit or Debit Card
	Registration Type*	Select... Early Bird - $295 Early Bird Couple - $495 Regular - $345 Couples - $595
	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 Traditional credit/debit card transactions are no longer available. We have changed this policy in an effort to keep our costs down and your Congress investment low. Please provide your email address and we will send an invoice, via our PayPal account, with a link for you to complete the payment. You do not need to have a PayPal account to pay this way. Thank you.
	Email Address for Invoice*
Yes Yes No Please add me to your private mailing list (we do not share or sell lists).