Secretfield: 2534
Sponsorship Form
Arab Patients Education & Protection Program From Unethical Commercial Clinics
 اعلام وحماية المرضى العرب عن العيادات التجارية غير الأخلاقية
 

 How to use this Form:
  IMPORTANT : To complete the Order Form, please type 2534 in this box
Use one Form per sponsor
Type in the Form, on screen response, (complete applicable blanks). 
Press "TAB" to move between blank spaces. 
DO NOT CLICK ON "ENTER" while completing the form. If you do that, you will close the form and send incomplete Form!
DO NOT press the  "BACK" button because all information will be deleted if you leave this web page.


  I would like to sponsor the "Arab Patients Protection Program" From The Unethical Commercial Clinics:
Please click on the button for the sponsorship category of your choice:
 
Platinum   1 year: $1000   3 years: $2700   5 years: $4000
Gold         1 year: $750   3 years: $2025   5 years: $3000
Silver     1 year: $500   3 years: $1350   5 years: $2000
Standard     1 year: $250   3 years: $675   5 years: $1000


PAYMENT

    1. USA Dollars, Checks only, no credit cards.
    2. Sponsorships are paid in full and in advance
    3. USA Sponsors
      • Payment by checks drawn on American banks.
      • Check Number  
    4. NONE USA Sponsors
      You may pay by wire, electronic transfer of funds (
      please see - Sending The Sponsorship Form, below)
      On Line Tracking  Number (None USA Clients) 
    5. Payment Date 

Contact Information:
If a clinic or a hospital decide to sponsor itself, then it is sufficient to complete only Section B.

A. Sponsor (local distributor, international company... etc.):

First Name
Middle Name
Last Name
Title
Business Name
Number  Street  Suite #
City
State/ Country Zip Code
Area Code
Telephone Number
FAX Number 
E-mail Address
Web Site Address 

B. Sponsored Clinic or Hospital

First Name
Middle Name
Last Name
Title
Business Name
Number  Street  Suite #
City
State/ Country Zip Code
Area Code
Telephone Number
FAX Number 
E-mail Address
Web Site Address 

Sending The Sponsorship Form

Please click on the method used to send your sponsorship payment:
.
.USA Sponsors: Please complete, then print the Order Form and mail it with your check to:
Doctors' Marketing Service
P.O. Box 748 , Lake Forest, California 92609-0748

  Non-USA Sponsors: Electronic transfer of funds: To avoid delays in processing your order

 
.
Kindly send the completed form on line. Once your information was received,
we will send you the bank account information for transfer of funds. 

>>> Please Review The completed Form before you click on "Send It in". <<<
.

E. Mail  ceo.consultant@gmail.com

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