Mental Health Order Form
Step 1 of 5 - CUSTOMER DETAILS
20%
Date of Order
*
Date Format: DD slash MM slash YYYY
Organisation Name
*
Contact Name
*
First
Last
Street Address
*
City
*
State
*
New South Wales
Queensland
South Australia
Tasmania
Victoria
Western Australia
Australian Capital Territory
Northern Territory
Postal Code
*
Enter delivery address if different to street address above.
Delivery Address
City
State
New South Wales
Queensland
South Australia
Tasmania
Victoria
Western Australia
Australian Capital Territory
Northern Territory
Postal Code
Job Title
*
Email
*
Phone
*
Participant Workbook
*
Price:
$ 35.00
Quantity:
Facilitator Guide
*
Price:
$ 35.00
Quantity:
Sub Total
Shipping
*
NSW
QLD
SA
TAS
VIC
WA
ACT
NT
Total
Commencement Date
*
Insert date. Note: this is the date which you anticipate your first course will commence.
Date Format: DD slash MM slash YYYY
Payment Terms: On receipt of invoice
This Licence Agreement is between Health Television Network (HTN) and the Customer, of whose details appear in the Customer Details section of this form. This Agreement is dated as of the Commencement Date which is set out above. I acknowledge that I will read the HTN Terms and Conditions that will appear in the next screen and I will either accept or reject the HTN Terms and Conditions, on behalf of the Customer, as its duly authorised representative.
Name
*
First
Last
Date
*
Date Format: DD slash MM slash YYYY
Position/Title
*
Subject to the Customers compliance with this Agreement, during the Term, HTN will provide to the Customer for use by Facilitators and Participants, access to the HTN Bridge online platform for Assessments, Video content, downloadable Learning Resources, as well as all current tools and resources relating to the Spiritual Care Series.
The total number of Participant Logins allocated under this Agreement may not at any time exceed the total number paid for by the Customer as nominated in the Product Selection on this order form, but can be increased at any time upon payment of the additional fees current at that time.
HTN will invoice the Customer on the nominated Commencement Date.
Terms and Conditions
*
I have read and agree to the terms and conditions
Phone
This field is for validation purposes and should be left unchanged.
