Products Price Quantity Total

Products		Price	Quantity	Total
Mindful Eating for Diabetes Class for Employees of State of Arizona	$179.00	1	$179.00
Subtotal			$179.00

Mindful Eating for Diabetes Class for Employees of State of Arizona

$179.00

Subtotal $179.00

* You will be prompted to enter you Employee Identification Number (EIN) after you place the order. The number is only required for employees participating in Health Impact Program.

Billing Information
* First Name
* Last Name
Company Name
* Address - Line 1
Address - Line 2
* City
State
* Zip Code
* Country
* Phone Number
* Email Address

Order Summary
Subtotal	$179.00
Order total	$179.00

Payment Information
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Credit Card Type	Credit Card Number	Expiration Date	Security Code

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