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

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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)

Marijuana Diversion Program Payment*

Price:

Fee is non-refundable.

Payment – Marijuana Diversion Program

PAYMENT: Marijuana Diversion Program