Order Form

Payment Information
Credit Card #: __________________________
Expiration Date: ____/ ____/  (mm/YY)
Cardholder's name: _____________________
CVV or CVC: _____________________________
Signature : ______________________________
Billing Info : ____________________________

Visa    MasterCard    Discover   
American Express   
Others (Type Here)   _________________

Personal Information
Name: ________________________________
Address: ______________________________
Address Line 2: _______________________
City: __________________________________
State: _________________________________
ZIP: ___________________________________
Phone: ________________________________
Fax: ___________________________________
Email: _________________________________

If you want to make the payment through check or ACH please E-mail us at: cs@virtual-webinar.com

Conference Title: CMS Hospital Improvement Rules 2021
Conference Date: Nov 19, 2021
Quantity Price Total
Recording $109
DVD $119
Recording + DVD $269
Transcript (Pdf) $109
Recording & Transcript (Pdf) $259
DVD & Transcript (Pdf) $269
Coupon Code
Total
Please send the completed order form via fax or e-mail
Note: All the order related material (Presentation, Transcript etc.) shall be fulfilled through the included email address only.

For any queries call at +1-866-879-1354 or email at cs@virtual-webinar.com