Online Registration is only for new attendees; if you are an existing member please register through Empire's member portal.

$6,000.00
Spring Discount Applied

$1,599.00
Spring Discount Applied

$3,148.00
Spring Discount Applied

Total Amount Due: $10,747.00

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1 - Customer Information

First Name:

Last Name:

Medical Title:

Email Address:

Telephone:

Are you a Practice Owner?:

State License #:

Name of Account Rep who guided you, if any:

2 - Payment Information

eCheck Payment

Account Type:

Bank (Institution) Name:

Routing Number:

Account Number:

Name on Account:

Amount to be Charged:

Date:

Email for Confirmation:

I (we) understand that this authorization will remain in full force and effect until I (we) notify EMPIRE MEDICAL TRAINING, INC. in writing at the following:

Empire Medical Training, Inc.
2720 East Oakland Park Blvd, #102
Fort Lauderdale, FL 33306
(954) 525-4273
(954) 358-2860 (F)

That I (we) wish to revoke this authorization.

Name(s):

Date:

eSignature: (Please type your full name)

Credit Card Payment
(3.0% Covenience fee)

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3 - Billing Information

Address:

Address 2:

I acknowledge that I have read and agree with the Empire Medical Training terms of service, privacy policy, and cookie policy.

Amount to be charged: $10,747.00 + $322.41 Credit Card Convenience Fee