Payment Information:
___ Mailing a Check     ___  Credit Card    ___   Will Telephone with Credit Card

Please complete the following if paying by Credit Card or contact Natalie Wade at 678-839-4270 to provide your credit card information.


Type of Card:  ___ Visa   ___ Mastercard  ___ American Express    ___Discover

Cardholder Name as it appears on card:  ___________________________________________________

Billing Address, City, State ZIP ___________________________________________________________

Card # __________________________________________________________

Expiration Date ________________             Security Code  _________________

If mailing a check:

Greenway Medical Technologies Inc.
Attn: Regional Conference Training Dept.
121 Greenway Blvd.
Carrollton, GA  30117   
Phone:  678-839-4321      Fax:  678-839-4245

Please Fax this registration form to :  678-839-4245

Please Note:  Space is Limited.  Your space will be confirmed upon receipt of payment.