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 training 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 training fees*

Enter the amount to charge
Name of Trainee?*
Application fee

$80 if not already paid
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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Name
This field is for validation purposes and should be left unchanged.