Musculoskeletal Ultrasound Course Name First Middle Last Credentials Organization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Office PhoneFaxEmail Registration Fee Price: Regular Attendance before July 1, 2022 - $1500.00Registration Fee Price: Regular Attendance after July 1, 2022 - $1750.00Total Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name SignatureRefund requests will be honored (less $50.00 processing fee) if we are notified of cancellation in writing by July 31, 2022. We reserve the right to cancel this course.HiddenDate MM slash DD slash YYYY
