Christian Health Service Corps

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Thank you for registering for the CHSC Ultrasound Workshop to be held the afternoon of November 16, 2019. If you would also like to register for the morning Suture Workshop, please click here. You must register separately for each workshop.

REGISTRATION

Qty

Description

Amount

Total

Ultrasound Workshop

$39.00

Total: $39.00

Registrant Information

Registrant Name: *

If registrant address is the same as Payer Information, please answer information after zip code.

Address:

City:

State:

Zip Code:

Cell Phone: *

Home Phone: *

Email: *

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *