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

This enrollment is the first step in getting started with the MedLog program. Upon completion of this form, you will be contacted to organize payment and begin your studies.

If you have questions about MedLog’s content or modalities, please view the detailed course content and learning methodology information available on the Humanitarian Logistics Certification Program website. Specific questions can be e-mailed to info@fritzinstitute.org.

Please note: this form can be a little temperamental. Please put an “X” in any box for which you do not have information, even if not marked as required.

Please note: Regsitration (this form) is NOT part of any scholarshop application process. Information about scholarship opportunities (including forms) is available here.

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
With questions, please contact info@fritzinstitute.org.
 
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