Thank you for submitting the agreement. The final step of enrollment is to order your supplies below. Order Collection Transport Packs6 - $50012 - $1,00018 - $1,500Auto-Ship Please auto-ship me the same quantity of collection transport packs when my supply gets low. Launch Kits Price: $285.00 Quantity: *Minimum order quantity of one (1) required with initial order.Includes: One-sheet displays and trifolds, including stands, for your office, one location, and five referring offices.Total $0.00 Shipping Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Credit Card American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Payment Authorization I hereby authorize Stemodontics to bill the credit card above for the above selected amount. I further authorize Stemodontics to - if selected - auto bill and ship additional CTP's as demand necessitates. Date Date Format: MM slash DD slash YYYY Name First Last CAPTCHA
