| I would like to register for the following workshop and my title is: |
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$1950: MD, DO, MBBS |
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$1500: RN, NP, PA/C, FNP |
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| Where did you hear of ASNA:
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| 2008 LIPODISSOLVE programs: |
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February | |
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March | IL |
April | TX |
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June | NY |
July | IL |
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August | CA |
September | NV |
October | IL cancelled |
November | NV |
Lipodissolve course includes certificate, and one year membership and consultation.
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| Contact Details |
| Your name* |
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| Specialty |
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| Clinic Name |
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| Clinic Address* |
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| City* |
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| State |
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| Zip/Post code* |
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| Country* |
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| Payment details* |
| Card type |
VISA |
Mastercard |
| Card Number |
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| Cardholder's Name |
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| Exp. date |
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| CVC Code |
Last 3 digits on back of card |
| Billing Address |
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| City/Town |
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| State |
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| Post Code |
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| Country |
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| Your name and medical title as it should appear on the training certificate: |
| Certificate* |
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You must fax your medical license to ASNA
at +1 (208) 330-9903 with your registration
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| Phone* |
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| Fax* |
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| E-mail* |
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| Retype Email* |
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| Your website |
Will be added to your patient referral details |
| Comments? |
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| Digital Signature |
Approval*
Please read the conditions below for your Electronic Signature approval. |
I accept all registration charges as indicated in the details provided by me above and the conditions herein. Approved charges are to be billed to my credit card.
I understand that I will be asked to provide a follow-up report on Lipodissolve procedures within a certain time-limit of the course date when attending a Lipodissolve course.
All charges are processed by ASNA, Ltd. The course fee is non-refundable. Course date can be exchanged for another program date if you are unable to attended.
Accounts due by applicant that are issued for collections in events of non-payment, reversal of fee or cancellation of payment will be billed to you with revolving 18% penalty per month on total amount due, banking fees plus collection fees until paid in full. Legal fees and penalties may apply in addition if applicable. Program schedules are depended on services and arrangements that are independent from ASNA and may be subject to alterations or changes without prior approval. ASNA is not responsible for any costs accrued from unforeseen cancellations of dates/programs, or cancellations due to natural calamities, weather patterns, or other unforseen emergency situations which may effect or cancel programs or transportation to the location where programs are held. |
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