Device Rental Payment Form
Order Details
Email Address
MDRT ID
Full Name
Quantity (Units)
Per unit: USD 70 refundable, USD 5 Admin Fee (4 days rental)
Price per unit:
$75.00
Quantity:
1 units
Total:
$75.00
Payment Details
Swipe
Full Name
Card Number
Expiry Date
CVC
I agree to the terms and conditions
Pay $75.00 Now (Card)