Membership Application - International Health Facility Diversion Association

[MM_Form type='checkout'] [MM_Form_Message type='error']

[MM_Form_Section type='accountInfo']

Account Information

First Name: [MM_Form_Field type='input' name='firstName' customAttributes='placeholder="First Name"']

Last Name: [MM_Form_Field type='input' name='lastName' customAttributes='placeholder="Last Name"']

Email: [MM_Form_Field type='input' name='email' customAttributes='placeholder="Email Address"']

Password: [MM_Form_Field type='input' name='password' customAttributes='placeholder="Password"']

Phone: [MM_Form_Field type='input' name='phone' isRequired='false' customAttributes='placeholder="Phone Number"']

Organization: [MM_Form_Field type='custom' id='1' isRequired='true' class='']

Title: [MM_Form_Field type='custom' id='2' isRequired='true' class='']

Address 1: [MM_Form_Field type='custom' id='3' isRequired='false' class='']

Address 2: [MM_Form_Field type='custom' id='4' isRequired='false' class='']

City:[MM_Form_Field type='custom' id='5' isRequired='false' class='']

State:[MM_Form_Field type='custom' id='6' isRequired='false' class='']

Zip:[MM_Form_Field type='custom' id='7' isRequired='false' class='']

Country:[MM_Form_Field type='custom' id='8' isRequired='false' class='']

[/MM_Form_Section] [MM_Form_Section type='billingInfo']

Billing Details

Credit Card: [MM_Form_Field name='ccNumber' customAttributes='placeholder="Credit Card Number"']

Security Code: [MM_Form_Field name='ccSecurityCode' customAttributes='placeholder="Security Code"']

Expiration Date: [MM_Form_Field name='ccExpirationDate']

Billing Address

Address: [MM_Form_Field name='billingAddress' customAttributes='placeholder="Billing Address"']

City: [MM_Form_Field name='billingCity' customAttributes='placeholder="Billing City"']

State: [MM_Form_Field name='billingState' customAttributes='placeholder="Billing State"']

Zip: [MM_Form_Field name='billingZipCode' customAttributes='placeholder="Billing Zip Code"']

Country: [MM_Form_Field name='billingCountry']

[/MM_Form_Section] [MM_Form_Section type='shippingInfo']

Shipping Address

Shipping Method: [MM_Form_Field name='shippingMethod']

Shipping is the same as billing [MM_Form_Field name='shippingSameAsBilling']

[MM_Form_Subsection type='shippingAddress']

Address: [MM_Form_Field name='shippingAddress' customAttributes='placeholder="Shipping Address"']

City: [MM_Form_Field name='shippingCity' customAttributes='placeholder="Shipping City"']

State: [MM_Form_Field name='shippingState' customAttributes='placeholder="Shipping State"']

Zip : [MM_Form_Field name='shippingZipCode' customAttributes='placeholder="Shipping Zip Code"']

Country: [MM_Form_Field name='shippingCountry']

[/MM_Form_Subsection]

[/MM_Form_Section] [MM_Form_Section type='coupon']

Coupons

[MM_Form_Field name='couponCode'] Apply Coupon

[MM_Form_Message type='couponSuccess'] [MM_Form_Message type='couponError']

[/MM_Form_Section]

[MM_Form_Data name='productName' useAccessName='false']

[MM_Form_Data name='productDescription']

Product Price: [MM_Form_Data name='productPriceDescription']

[MM_Order_Decision isShippable='true']

Shipping Price: [MM_Form_Data name='shippingPrice']

[/MM_Order_Decision] [MM_Order_Decision isDiscounted='true']

Discount: [MM_Form_Data name='discount']

[/MM_Order_Decision]

Total Price: [MM_Form_Data name='totalPrice']

[MM_Member_Decision isMember='true'][MM_Form_Field type='input' name='gift'] Is this a gift?

[/MM_Member_Decision]

[MM_Form_Button type='all' label='Submit Order' color='orange']

[/MM_Form]