Membership Registration

Registration Summary
Date / Location
PRP 3-Hour Demonstration Miami, FL
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Total Amount Due:
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: *
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: *
Amount to charge in 2nd credit card: *$

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

Upgrade Available: For only $3,000.00 more, you qualify for an upgrade to a Platinum Membership and you will have access to all 24 Aesthetic & Medical Workshops FREE (Over $20,000 value), if interested click here

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Amount to be charged: $599.00


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