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Medium PTO Membership

Customer Information Form

* indicates a required field

Full Name:*

Address Line 1:*

Address Line 2:

MailStop/Floor/Apt#

City:*

Select ‘Other’ if not USA or Canada...

State/Province:*

Zip/Postal Code:*

Enter ‘NA’ if not USA or Canada...

Country:

Phone Country Code:

Phone Number:*

E-mail:*

I have read and agree to abide by the general terms and conditions*

I have read and agree to abide by the Professional Training Organization special terms and conditions*

I agree to the level and extent of allowed use of the materials, i.e., medium (between 101 and 500 student class days per year). I am identifying the specific level I am purchasing * :

Whitemarsh Information Systems Corporation

2008 Althea Lane Bowie, Maryland 20716 USA

For Sales and Corporate: (1) (301) 249-1142 Whitemarsh@Wiscorp.com

Copyright 1981 - 2008, Whitemarsh Information Systems Corporation  Proprietary Data, All rights Reserved