ELECTRONIC COURSE COMPLETION FORM

Thank you for your enrollment in this Institute of Addiction Awareness
HOMESTUDY Program.
We hope you will enjoy your participation in this course.
INSTRUCTIONS:
1. Read course text.
2. Take Post Test using Answer Sheet.
3. Verify Post Test responses by reviewing course text.
4. Complete this form (return original - keep a copy for your files).
5. Mail or FAX to:
    Institute of Addiction Awareness
    190 Red Rock Trail
    Sedona, AZ 86336
    FAX 928-550-4926 (must FAX both pages)
INFORMATION: The following information is necessary for the issuance
of your certificate.
                             PLEASE TYPE OR PRINT NEATLY!

Course Title ______________________________________

Date Started ____________

Name _________________________________________

Address_________________________________________________

City/State/Zip____________________________________________

Phone: home ___________________ work _____________________

Lic.: Type _____________ # _____________

Cert.: Type ______________ # ____________

Email:  _______________________________

Firm:   _______________________________


EVALUATION: Please evaluate your course using this scale:
1=below average 2=average 3=above average 4=excellent
1 2 3 4 The extent to which this course met the objectives (see catalog).
1 2 3 4 The adequacy of the instructor's (author) mastery of the subject.
1 2 3 4 The utilization of appropriate teaching methods (HOMESTUDY).
1 2 3 4 Efficiency of course mechanics (mail order procedures).
1 2 3 4 The applicability or usability of new information.

Additional Comments:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Please allow IAA 10 working days for the processing of your certificate.
If you need more rapid processing see OVERNITE FAX-BACK below.
Courses completion date(s) are the date FAXed or postmarked to IAA.
No duplicate certificates issued after 60 days from completion without
additional fee.
(    ) Return certificate by mail (to address above)
                       -OR-
(    ) Return certificate by FAX to: (      )  _________________________
(    ) FAX BACK service - your exam scored and certificate
       FAXED next business day - \$10.00 surcharge 

NOTE: There is a $5.00 surcharge for mail and FAX service outside the USA.

Credit Card  (   ) VISA   (  ) MC   (  ) AMEX   (  ) DISCOVER

Card # ___________________________

Exp. Date ________________________

Authorized Signature __________________________________

(    ) US NAVY/MARINE personnel - check here to receive required
       critique form.

- - - - - - - - - - - - - - - - - - - - -  Page 2 - - - -  - - - - - - - - - - - - - - - - - -

       Post Test Answer Sheet - Circle Correct Answers
01.  a  b  c  d    26. a  b  c  d    51. a  b  c  d    76. a  b  c  d
02.  a  b  c  d    27. a  b  c  d    52. a  b  c  d    77. a  b  c  d
03.  a  b  c  d    28. a  b  c  d    53. a  b  c  d    78. a  b  c  d
04.  a  b  c  d    29. a  b  c  d    54. a  b  c  d    79. a  b  c  d
05.  a  b  c  d    30. a  b  c  d    55. a  b  c  d    80. a  b  c  d
06.  a  b  c  d    31. a  b  c  d    56. a  b  c  d    81. a  b  c  d
07.  a  b  c  d    32. a  b  c  d    57. a  b  c  d    82. a  b  c  d
08.  a  b  c  d    33. a  b  c  d    58. a  b  c  d    83. a  b  c  d
09.  a  b  c  d    34. a  b  c  d    59. a  b  c  d    84. a  b  c  d
10.  a  b  c  d    35. a  b  c  d    60. a  b  c  d    85. a  b  c  d
11.  a  b  c  d    36. a  b  c  d    61. a  b  c  d    86. a  b  c  d
12.  a  b  c  d    37. a  b  c  d    62. a  b  c  d    87. a  b  c  d
13.  a  b  c  d    38. a  b  c  d    63. a  b  c  d    88. a  b  c  d
14.  a  b  c  d    39. a  b  c  d    64. a  b  c  d    89. a  b  c  d
15.  a  b  c  d    40. a  b  c  d    65. a  b  c  d    90. a  b  c  d
16.  a  b  c  d    41. a  b  c  d    66. a  b  c  d    91. a  b  c  d
17.  a  b  c  d    42. a  b  c  d    67. a  b  c  d    92. a  b  c  d
18.  a  b  c  d    43. a  b  c  d    68. a  b  c  d    93. a  b  c  d
19.  a  b  c  d    44. a  b  c  d    69. a  b  c  d    94. a  b  c  d
20.  a  b  c  d    45. a  b  c  d    70. a  b  c  d    95. a  b  c  d
21.  a  b  c  d    46. a  b  c  d    71. a  b  c  d    96. a  b  c  d
22.  a  b  c  d    47. a  b  c  d    72. a  b  c  d    97. a  b  c  d
23.  a  b  c  d    48. a  b  c  d    73. a  b  c  d    98. a  b  c  d
24.  a  b  c  d    49. a  b  c  d    74. a  b  c  d    99. a  b  c  d
25.  a  b  c  d    50. a  b  c  d    75. a  b  c  d    100 a  b  c  d

Statement: I certify that I have completed this independent study program
according to the instructions provided and that all work is my own.

Signature ____________________________ Date ___________

NOTE: Orders paid by personal check will be held for two weeks.