Irlen Dyslexia Centre Sydney For Reading and Perceptual Disorders ---------------------------------------------------------- PO Box 478, Burwood NSW 1805 Clinic: Level 4, 9 Deane Street, Burwood Phone: 02 9747 1122 Fax: 02 9747 1422 Website: www.dyslexiaservices.com.au Email: dgtirlen@yahoo.com.au

REGISTRATION FORM

BUSINESS NAME: ________________________________________________________________

ADDRESS: _______________________________________________________________________

PH: ___________________________________ FAX: _____________________________________

EMAIL: __________________________________________________________________________

NAME OF PERSON ATTENDING COURSE:

_________________________________________________________________________________

PART A                                   $165.00

PART B (Lunch)                      No Cost

PART C (PASS Course)            $55.00    Must have completed Part A on the day.

Total Amount Payable $ ___________________

Payment options:

Visa No. _______________________________

Exp: __________________________________

Cheques made payable to: Irlen Dyslexia Centre