To pay by check or money order
Orders for 1 program only, complete Sections A & C.
Orders for 2 or more programs, complete Sections A & B.
(*Note: If ordering 5 or more programs, you qualify for a volume discount. Contact us for details at:
info@nshcoa.com or 931.967.0894)
Section A PLEASE PRINT LEGIBLY
| Product Description | Quantity | Total Cost |
Add S&H | Total Due |
|
Health Coaching Made Easy for Health Care Providers: $385 each Shipping charges: 1 program $15 2-4 programs - same location: $30 5 or more programs - contact us at: info@nshcoa.com for volume discount and shipping charge All International orders include S/H: $37.50 USD for each program ordered |
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|
Make check or money order payable to: Miller & Huffman Outcome Architects, LLC (MHOA) Mail To: MHOA 221 Victor Lane Ringgold, GA 30736 |
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SECTION B (Complete only if ordering 2 or more programs)
Upon receipt of payment and this order form, the contact person listed will receive an email containing a Group ID and login instructions, both to be shared only with each person receiving a program. Each person is required to enter their personal information into the NSHC website in order to activate their personal membership and/or take the exam or post test.
(All Programs in the order will be shipped to the Location entered below)
Company Name: __________________________________________________________________________________
Contact Person: ___________________________________________________________________________________
Street Address: ____________________________________________________________________________________
City: _________________________________________________________________ State: _______ Zip: ____________
Email: ___________________________________________________________ Phone: __________________________
Country Code
(if applicable): _____________________________________________________________________________________
SECTION C (Complete only if ordering one program)
1. Full name w/ middle initial: __________________________________________________________________________
2a. Address/City/State/Zip: ____________________________________________________________________________
2b. Shipping Address (if different) ______________________________________________________________________
3. Credential (MD, RN, RPT, etc) _____________
4. Active License #: _______________________
5. Licensed in what State? _________________
6. Email address: __________________________________________________________________________________
7. Phone: ______________________________