Order: Mindex Profile - Professional Trial Version

I request authorization for the Professional Trial version of Karl Albrecht International's Mindex Profile (on-line version). I understand that acceptance of my request 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 $50.00. I will receive a confirmation and my temporary ID Code and Password by email. I understand that, once I access the Mindex Online Profile my fee is not refundable.

I understand that the fee for access to this trial version is applicable to the full certification fee if I decide to enroll as a Certified User within 30 days.

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.

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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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