Online Registration is only for new attendees; if you are an existing member please send an email to [email protected] with your request for registrations. If you have any questions please call 866.366.1576.

Total Amount Due: $13,499.00

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1 - Customer Information

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Email Address:

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Are you a Practice Owner?:

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2 - Payment Information

eCheck Payment

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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.

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Credit Card Payment
(2.5% 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: $13,499.00 + $337.48 Credit Card Convenience Fee


Blue Diamond Membership	$13,499.00 remove
1 Year Membership + 1 Year FREE

remove all discount / vendor code Total Amount Due: $13,499.00