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Video Purchasing Form

Customer Information

  Mr.     Ms.
First Name
Last name
Mine ID number
Day Phone
E-mail Address to confirm order


Please check the box of the video you wish to order. Both videos are available only in DVD format. The English and Spanish versions are on same DVD.

First Aid in the Mining Industry
MSHA Inspection are you Ready?

The prices are the same for both videos. Please check the box that applies to your organization.

Free for mines located in Texas
$20 each for mines located outside of Texas
$50 each for non-mining affiliated interested parties

Payment Information

Total amount to charge card
Account Number
Expiration Date
Credit Card Mastercard
American Express
Name as it appears on card

By clicking the "Purchase" button of this Web form, I certify that all the information completed in this registration form is correct.

I further certify that by clicking the "Purchase" button below, that I am the above-named individual or form preparer and that I authorize the Professional Development Center to charge my credit card.



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