CERTIFICATION IN HUMANITARIAN MEDICAL LOGISTICS PRACTICES (MedLog) PROGRAM ENROLLMENT FORM  
 

Please contact Learning Logistics Alliance or Fritz Institute for pricing information and detailed course student guide before completing this form.

All Information Marked with an Asterisk ( * ) is Required

Contact Info
First Name *
Last Name *
Title  
Date of Birth *
Phone Number *
Address 1 *
Address 2  
City *
State / Province *
Postal Code *
Country *
Organization Details
Organization Name *
Position *
Organization Phone  
Organization Address 1  
Organization Address 2  
Organization City  
Organization State / Province  
Organization Postal Code  
Organization Country  
Correspondence to be sent to  
Preferred Email: ( at least one of the two emails is required )
E-mail (Home) *
E-mail (Organization) *
Preferred Email (one of the above)  
Supervisor Name  
Supervisor E-mail  
Payment Options
I am self financing *
My Organisation will Pay *
Purchase Order Number  
Invoice to be sent to
Invoice Name *
Invoice Position *
Invoice Address 1 *
Invoice Address 2  
Invoice City *
Invoice State / Province *
Invoice Postal Code *
Invoice Country *
Fees will be paid *
Additional Info
How did you hear about the MedLog program?
 
 
 
 
+ For more information
Please contact :
david.jackson@logisticslearningalliance.com
or
MedLog@fritzinstitute.org
For CILT, please contact :
janet.desilva@ciltuk.org.uk
 
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