Second Payment Form - Annahid Dashtgard

Second Payment for BIPOC Leader Lab

Jan. to June 2023

Coaching Second Payment

Your Information

First Name

Last Name

Pronouns

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

Position

Organization

Email

Phone

Payment Method

I currently reside:

In Canada

Outside of Canada (international)

Payment Currency

Payment Currency

Payment Option

Payment by

Credit Card

Organizational invoice- as arranged

Price

Agreed Price (after tax)

Agreed Price

Payment

Credit Card

Billing Address

Billing Address

Billing Address

Billing Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country