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

Catalog Number : wpnad1660-iol
Webplay Name : CMS ASC Curriculum: Medical Staff & Nursing Service Conditions of Coverage
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)______