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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