AMBA Compliance Online Seminar Registration Form

Please print and send along with your payment to AMBA.

Be sure to include your email address clearly written so we can send your access password and user name via email.

___Online Compliance Seminar $69

Member #___________

Name of Seminar Attendee:

Business Name:

Address:

City ST Zip:

Phone Number:

Email Address(es):

Email Address:

Send registration to:

American Medical Billing Association
4297 Forrest Drive
Sulphur, OK 73086

Credit Card Type: ___Visa ___MC ___Discover

Expiration Date: __________

Name on Card:______________________________(Print)

Card Number:________________________________

Signature:__________________________________

Or, fax your form with a credit card payment to (580) 622-5810. Be sure to include the expiration date and name on the card when paying by credit card. Visa, MC and Discover accepted.