Empire Medical Training - Registration System

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.

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Date:

eSignature: (Please type your full name)

Credit Card Payment
(3.0% Covenience fee)

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CVV:

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: $20,187.00 + $605.61 Credit Card Convenience Fee

Your Registration

Sub-Total: $20,387.00

Choose Payment Type

1 - Customer Information

2 - Payment Information

eCheck Payment

Credit Card Payment
(3.0% Covenience fee)

3 - Billing Information

Your Registration

Sub-Total: $20,387.00

Choose Payment Type

1 - Customer Information

2 - Payment Information

eCheck Payment

Credit Card Payment(3.0% Covenience fee)

3 - Billing Information

Credit Card Payment
(3.0% Covenience fee)