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First Name:

Last Name:

Address:

City

Country

P/code

Phone(Hme)

Phone(Wrk)

Mobile

Country of Origin:

New Zealand

Australia

Other

Residency:

New Zealand

Australia

Other

Course you wish to study:

	Clinical Ayurvedic Lifestyle Consultant (Certificate)
	Clinical Ayurvedic Lifestyle Practitioner (Diploma)
	Ayurvedic Fundamentals

Study Option:

Distance Learning

Face to Face

Full Time

? Do you have any special learning requirements or difficulties that we may need to address?(Please List below)

? Please state ( Below) why you have chosen to study Ayurveda.

I have read and understand the policies of the AIAS and accept them.

I am forwarding a registration fee of $200 using the following method (Please make cheques/money orders payable to AIAS.) VISA or MASTERCARD only.

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