PROFESSIONAL MEDICAL EDUCATION ASSOCIATION, INC.
ORDER FORM

Please print this page, fill in the blanks complete with payment information, then fax to 01-305-946-0232,
or mail to PO Box 997, Grove City OH 43123, USA.
Your order will be shipped upon receipt of your credit card information and signature, or check through the mail. Please include your email address for confirmation of receipt of order. All payments in U.S. Dollars, checks drawn on a U.S. Bank only. Allow 2 weeks for delivery. In the U.S. call 800-435-3131 for questions, 01-305-851-8081 outside the U.S., or Skype name "LaserTraining".
Overnight FedX shipments can be provided at additional cost or your FedX account #.

NOTE FOR ORIGINAL OR RE-ISSUANCE OF TRAINING CERTIFICATES:
Certificates will be mailed ONLY to the payor's address listed below

NAME:_______________________________________  Title:________________________

Institution / Business _____________________________________________________________________

Shipping Address _______________________________________________________________________

 City:_____________________________ State_________ Zip:______________

Tel: (____)_______________ Fax: (_____)_____________E-mail:_________________________________

Order:                         Date: ________________

Payment:  ____ Check Enclosed (US Bank);  ____Am Express Card;    ___ Discover Card;     ___ Visa;    ___ MasterCard

Credit Card # ______________________________________________________exp date____________

Name on card_________________________________  Signature ________________________________

Address of credit card billing if different than shipping address:
_____________________________________________________________________________________