To fax in your reservation, print off this page, fill in the blanks and fax to Instruct-online at 319-626-7257:
Catalog Number : wpnad1669-iol Webplay Name : CMS Ambulatory Surge Centers: Survey Protocols, Exit Conference & Post-Survey Activities Speaker : Sue Dill Price : $160 for 2 week access
All the information below is required: Organization's Name : ______________________________ Address : ____________________ City/State/Zip : ____________________ Contact Name : ____________________ E-mail address : ____________________ Phone Number : ____________________
___ Pay by Check (Payable to : Instruct-online) ___ Pay by PO (Payable to : Instruct-online) PO#____________________ ___ Pay by Credit Card (Mastercard or Visa) Card Number____________________ Name on Card____________________ Expiration Date______ Credit Card Verification Number (from back of card)______