INFACT USA

Registration Form

First Name:^*
Middle Initial:
Last Name:^*
Organization:

Type of Address^*
PO Box / Mail Stop:
Primary Address:^*
City:^*
State:^*
Zip:^*
Country:
Phone 1:^*	ext.
Phone 2:	ext.
Email:^*
Fax:

Continuing Education Credit

RN License #:
RN License State:
ALPP CLC #:
IBCLC #:
IBCLC Exam Year:

Registration Information

Location:^*

Course Tuition

Regular Tuition (per person)
$60 (US)	Regular Tuition

Notes

Payment Information

We are unable to hold a place for you without payment or a purchase order number.
If you are paying by credit card, please provide the address and information
associated with the credit card.

My Billing information is the same as above

First Name:^*
Last Name:^*
Organization:
Address:^*
City:^*
State:^*
Zip:^*
Billing Phone:^*	ext.
Email:^*
Payment Type^*
Credit Card #^*
Exp (MM/YY)^*
Verification #^*
PO#^*

$25 per person surcharge for POs / bill your agency

***The verification # is the 3 digit number on the back of your MC/VISA/Discover, or 4 digit number on the front of your AmEx.

By clicking submit you are authorizing Healthy Children Project Inc./Center for Breastfeeding to charge your credit card. You are also agreeing to HCP's terms and conditions

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