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Registration Form
Print this form, complete, then mail or fax 
to the address below:

for more information, call 1-877-480-9992

Personal & Company Information:  Please print clearly in ink - Your name will appear this way on the certificate

Participant Name: ___________________________________________________________________________________
                                                First Name                           Middle Initial                                                 Last Name

Company/organization name (if applicable):  __________________________________________________________

Date of Birth: (__________/_____/_____)   E-Mail Address:   ______________________________________________
                           (  year / mm  / dd   )
*Participants must be at least 16 years of age to register for the Livestock Medicines Education Program.


Telephone: _____________________________________  Fax: __________________________________________

Mailing Address:


__________________________________________________________    _______________________    ____________ 
 Rural Route or Street                                                                                              Town or City               Postal Code


County / District / Regional Municipality: ______________________________________________________________
Livestock Commodity Produced on Your Farm  (Please check appropriate box(es):

Equine Beef  Dairy  Goats Poultry  Sheep  Swine Other (specify) ________________
Course Information - I would like to register for the following course:

1st Choice:  Course # _______________ Location: ___________________________ Course Date: _________________

2nd Choice: Course#  _______________ Location: ___________________________ Course Date: _________________

Participant Fee:  $100.00 per person (This program is not funded by A.A.C.)

No Taxes on Fees.  NO REFUNDS

Cheque Enclosed      Money Order        Visa         MasterCard
  (Please make payable to University of Guelph -NSF Cheques will result in a $30.00 charge - No Post Dated Cheques)

If paying with Credit Card, please supply the following information:

Card #: _________________________________________________        Expiry: ____________________________ 

Name on Card:______________________________________________________
Personal information contained on this form will remain confidential and will be used by University of Guelph Ridgetown Campus to register participants in the Livestock Medicines Education Course, provide information/updates to the LMEP steering committee and to evaluate the impact and usefulness of the courses.  Complete this as accurately as you can.  Some  questions and/or statements may not pertain to your type of farming or employment; indicate N/A for not applicable.
Participant's Signature:  ____________________________________________________

Return completed form with payment to:
Livestock Medicines Education Program, University of Guelph Ridgetown Campus, Ridgetown, Ontario  N0P 2C0
OR Fax (with Visa or Mastercard info) to:  519-674-1560

For office use only:
                                Exam Mark:  ___________  Certificate Issued: ___________________  Expiry: __________________