Date

Name

Company

Address

City State Zip

E-mail Address
Telephone No. and Area Code

NOTE: Print this page and send with check payable to EMBN to:

Electronic Medical Billing Network of America, Inc.
51 Eton Court, Bedminster, New Jersey 07921
Phone 908-470-4100 FAX 908-470-4233
Email: merl@medicalbillingnetwork.com

---

Major charge cards accepted
For faster service, use your credit card. Fill out the additional information below, print this page and fax to: 908-470-4233

---

American Express Master Card Visa

Card Number

Date of Expiration

Name on Card

NOTE: Print this page and mail with check or fax with above credit card info to:
Electronic Medical Billing Network of America, Inc.
51 Eton Court, Bedminster, New Jersey 07921
Phone 908-470-4100 FAX 908-470-4233

Email: merl@medicalbillingnetwork.com

---

To order one or more of the other electronic medical billing titles available through EMBN, click on the link below . . .