Payment - Marijuana Diversion Program - Council on Chemical Abuse

Please note: The non-refundable $50.00 service fee payable is required per referral to participate in the program. Service fee and signed referral must be submitted before the participant is eligible to schedule his/her class.

PAYMENT: Marijuana Diversion Program

Billing Name*
Billing First Billing Last
Are you registering for yourself or someone else?*
Participant's Name*
Participant's First Initial Participant's Last Name
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
Phone*
Does Participant need Spanish Translation (¿Necesita traducción al español?)
- Yes (Sí)
- No
Marijuana Diversion Program Payment*
Price:
Fee is non-refundable.
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Payment – Marijuana Diversion Program

PAYMENT: Marijuana Diversion Program