Order: Mindex Profile Certification Course

I hereby apply for enrollment in Karl Albrecht International's Mindex Profile Certification Course (on-line version). I understand that acceptance of my application is contingent on a review of my professional qualifications (as provided below or otherwise supplied), and that enrollment may be refused to applicants who are judged unsuitable.

If accepted, my credit card will be charged USD $495.00. I will receive a confirmation and my temporary User ID and Password by email. I understand that, once I access the on-line Mindex Profile Certification Course, my enrollment fee is not refundable.

Upon completing the on-line course, including submission of a final quiz and confirmation of acceptance of the ethical standards for use of the Mindex Profile, I'll receive a certificate, together with a permanent User ID and password, which entitle me to purchase and use the Mindex Profile and related products from Karl Albrecht International.

I acknowledge that, if my member materials or products are to be shipped outside the United States, there will be an additional charge for the actual amount of the shipping cost.

All (*) fields are required
(*) First Name
(*) Last Name
Title / Department
(*) Company
(*) Street Address (No P.O. Boxes)
(*) City
(*) State/Province	(2-letter State Code for US)
(*) Zip/Postal Code
(*) Country
Telephone
(*) Email
Website
Gender	Male Female Non-binary Undisclosed
Send a Copy to Yourself?	Yes No
(*) In One Paragraph (1000 characters), please summarize your professional qualifications here (current occupation, organization, credentials, experience, business operation, etc.): How did you first discover the Mindex Profile?

(*) I confirm that I will adhere to the ethical use guidelines for using KAI profile products.

I am a Certified User of another KAI profile product, and I request a multi-profile discount for this additional certification. I will only be charged an administrative fee of $50 for my enrollment as a multi-profile user.
My ID Code is

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First Name (Exactly as on Card)
Last Name (Exactly as on Card)
Card Number	(No spaces or dashes)
Exp. Date (mm/yy)
Authorization Code	(3 or 4 digits, required)
	Billing Address:
Country
Street Address (As on Account)
Apt., Ste, Bldg. (Optional)
City
State/Province
Zip/Postal Code

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