MedNET 2006 - Special Payments

This form will lead to a secure credit card payment site, enabling for example exhibitors and sponsors to make payments to the Organizing Committee to make exhibition booth reservations and sponsorship payments. Please do not use this form to pay the registration fee (unless asked to do so) - use the Registration Form only. ] You will be forwarded to a secure site to enter your credit card information. Please note that a warning message will appear, stating that the security certificate belongs to ehealthcollaboratory.ca. Please click OK and proceed. Please note: PSiGate processes only Visa and MasterCard. Please fill in all fields:
Description:
Amount (CDN$):
First Name:
Last Name:
Company / Affiliation:
Address:
City:
State / Province:
Postal Code:
Country:
Telephone:
Facsimile:
Email: