paymentSubmission form

COMPLETE THIS FORM IF YOU HAVE PAID TO THE BANK FOR THE LIVE REVIEW COURSE AND MEDICAL TOURISM

Email:

First Name:

Last Name:

GSM Number:

Currency of Payment:

Dollars ($)

Naira (N)

Bank :

Fidelity

UBA

GTB

City Where Deposit was Made:

Date of Payment to the Bank:

Bank Teller or Deposit Slip Number (Optional):

Amount Deposited in Figures:

City of Choice for Training and Review:

Comments: