Registration Live Implants Mexico

First Name Last Name

Degree(s) Years in Practice Specialty

Address

City State Zip Code

Contact Phone: Fax:

Course Dates
 March 2012  July 2012 Noviembre 2012

Payment Options
Option A : Full Payment  $13,500
Option B : In-house Financing  $6,962,50
and 4 monthly payment of $1,740,62

CHECKS
Check enclosed payable to LIVE IMPLANTS CORPORATION

Check number Amount Check

CREDIT CARDS
I wish to charge my registration fee to the following credit card in the

Amount of
Credit Card Type
 Master Card  Visa  American Express  Discovery

Name on Card

Credit Card
Security Code Number Exp

For more information please call us at 305-271-9202 or Fax it to 305-271-9370
For more details please go to our disclaimer section

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