|
|
Participant First Name * | |
Participant Last Name * | |
Participant Email * | |
Participant Company | |
Participant Phone 1 * | |
|
Name on Card (if different) | |
|
Street Address 1 * |
|
Street Address 2 |
|
City * |
|
State * |
|
Postal Code * |
|
Country | |
|
|
Card Type * | |
|
Card Number * |
|
Expiration Month * | |
|
Expiration Year * | |
|
CVC * |
|
|
|
|
|
|
|

Important note: Please be very careful to enter your correct email address when filling out the order form above. If there is a typo in your email address, you will be not be able to receive your access information and other email communications, so please double-check for accuracy. If you do not receive your Access Details email immediately upon placing your order, please contact our Customer Support department right away at support.theshiftnetwork.com or 415-223-7565. This course is for educational purposes only. Neither the course leader nor The Shift Network is liable for possible damage incurred as a direct or indirect consequence of using the contents, advice or interpretation thereof. It is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care providers with any questions you may have regarding a medical condition or treatment and before undertaking a regimen, and never disregard professional medical advice or delay in seeking it because of something you have learned in this course or on our website. |
|
I have read and understand the terms of this agreement. |
|
(Enter your initials) |
|
|
|