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print off this page, send the information in an email
to katie@instruct-online.com

Catalog Number : wpcra1617-iol
Webplay Name : Critical Access Hospitals: Provider-Based Clinics
Speaker : Duane Abbey
Price : $225 for 2 week access

All the information below is required:
Organization's Name : ______________________________
Address : ____________________
City/State/Zip : ____________________
Contact Name : ____________________
E-mail address : ____________________
Phone Number : ____________________

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___ 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)______