Second Payment Form

Second Payment for BIPOC Leader Lab

Coaching Second Payment

First Name

Last Name

Pronouns

For example: she/her, he/him, they/them, etc.

Position

Organization

Phone

I currently reside:

In Canada

Outside of Canada (international)

Payment Currency

Payment Option

Payment by

Credit Card

Organizational invoice- as arranged

Agreed Price (after tax)

Agreed Price

Credit Card

Billing Address

City

State/Province

Zip/Postal

Country

If you are human, leave this field blank.