Miscellaneous Form Page 3

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Amount Owing: ($20.00)*
Price:
I hereby agree to pay the amount posted. This payment is non-contestable and non-refundable and is final sale. Your transaction will appear as Breath for Life Inc on your credit card statement. By entering your name in the field below you acknowledge and agree to the above.*

As on-line modules will be assigned (an email will be sent with instructions) when payment is received this course is final sale.
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Credit Card
Card Details
Cardholder Name
CAPTCHA
You must complete the captcha and then press submit. When you press submit you will see a turning circle. This means that your payment is being processed. Please allow time for processing and do not exit out. Thank you.

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