Online Payments Form

For advertisements, please use the Advertising Payments Form instead.

School/Company Name*

Enter N/A if does not apply
Name*
First Name Last Name
Email*
Phone*
This is a payment for:*
- Conference fees
- Consultant orientation deposit and/or balance due
- Recognition/consultation fees
- AMI/USA memberships
- Other
Conference Fees*

Enter the amount to charge
Who is the conference payment for?*
Consultant Orientation Fees*

Enter the amount to charge
Name of registrant if different than above*
Application Fee

Enter the amount to charge
Recognition Status Fees

Enter the amount to charge
Consultation Fees

Enter the amount to charge
AMI/USA Memberships Quantity
Price: $99.00
Enter # of memberships
Other Fees*

Enter the amount to charge
Please describe what this payment is for:*
Additional Information for AMI/USA
Total
$0.00
Payment
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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Comments
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