Please fill out completely the following Order Form. Once the form is completed, press the Submit button to send your information to Healthmaster^® Training. You may also print this form out and fax it to 1-248-960-8908. Please be patient. This form may take several seconds to transmit.

Thank you for your participation in Healthmaster^® Training.

Contact Information:

*First Name*
*Last Name*
*School/District*
*Street Address*
**Address (cont.)**
*City*
*State/Province*
*Zip/Postal Code*
*Office Phone*
*FAX*
*E-mail*

Product Information

Product Name
On Site Training		Call for Pricing 1-248-960-8900
Regional Training Seminars		$99 Per Session
Internet Training Modules		$69.00 per Module (Introductory Price)

Ordering Information

QTY		DESCRIPTION

Billing

*Purchase Order #*
*Account Name*

1.On Site Training
2. Regional Training Seminars
3. Internet Training Program Module