[Needs Updated] Seminar - Tampa Jan 2018 Vortala Digital

Seminar Registration

Complete this form to reserve your seat for "How to Grow Your Practice Using the Internet."

If you prefer to register over the phone, simply call (813) 327-5879.

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REGISTRATION CLOSED

90-minute seminar. Registration at 6:45pm for a 7:00pm start.

Registration:*

Single: $95 Group (entire practice): $145

How many will attend?*

Attendee Names:*

Please list the names and titles of all attendees from your practice.

Contact Information

Role*

Name*

Prefix

First Name

Last Name

Email*

Practice*

Enter your practice name.

Phone*

Best daytime contact phone number.

country

Billing Details

Registration Fee: $

Promotional Code

If you have a promotional code enter it here and click "Apply Discount" above.

How would you like to pay?*

Credit card Send me an invoice

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If you’d prefer to register over the phone, please call (813) 327-5879.

Credit Card Number*

Name on Card*

Billing Address*

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Address Line 2

City

State/Province

ZIP / Postal

Expiration Date*

Card Verification Code*

3 digit code on the back of your card (4 digits for Amex)

brand

Source Description

Lead Source

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invoice

yes no comp

Address Invoice To:*

First Name

Last Name

Mail Invoice To:*

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City

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