Membership Registration

Registration Summary
Conference
Date / Location
Price
Diamond Membership + Virtual 1 Year + 1 Year FREE Membership
$4,999.00
remove all
Total Amount Due:
$4,999.00
vendor code (if any)

Registration Buyer
   
First Name*
Last Name*
Medical Title*
Email Address: *
Telephone: *
Are you a practice owner?*
Name of Account Rep who guided you, if any:

State License #:


Payment - Empire-Split-Pay™
   
Credit Card: *
Credit Card Number: *
Expiration Date: *
CVV*
Amount to charge in this credit card: *$
 (no commas or dots please)
Payment - 2nd Credit Card
   
2nd Credit Card: *
2nd Credit Card Number: *
Expiration Date: *
CCV*
Amount to charge in 2nd credit card: *$
  


Billing Information: (address where you receive your monthly credit card statement)
   
Country: *
Address: *
Address:
City: *
State: *
Zip Code: *

  By clicking "Pay Now", 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: $4,999.00


NEED FINANCING?

No Payments + No Interest if paid in full in 6 months using: