ORTOPEDI.ORG WEBSITE "Live to be Taller"

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PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION :
First Name
Last Name
Title
Organization
Work Phone
Home Phone
FAX
E-mail

PAYMENT BY :
Amount Charge	$138.00

WIRE TRANSFER INFORMATION (FOR PAYMENT BY WIRE TRANSFER)

Bank Name
Reference Number _{(if available)}

CREDIT CARD INFORMATION (FOR PAYMENT BY CREDIT CARD)

	BILLING
Credit Card
Cardholder Name
Card Number
Approval Code (Amex)	_{Approval Code is the 4 numbers above your Card Number}
Expiration Date
_{If you pay by credit card, shipping address should be the same with your billing address}

	SHIPPING
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

PLEASE INDENTIFY AND DESCRIBE YOUR SELF :

First Name
Last Name
Date of Birth
Gender	Male Female
Height
Weight

Signature 1 Signature 2

Note:
If you pay by Credit Card, please attach a copy of your Credit Card, Driver's License/Identification Card (front and back) along with this order form. This is very important and required by your Card Company (Amex, Visa, and Master Card) to make sure proper identification and to prevent in appropriate or unauthorized usage of your card.
Also, please be advised that the course fee is non-refundable.