1.Your Full Name & Practice Name

2.Please select your preferred access package:

Standard Access (4 seats) $4,997

Standard Access (8 seats) $8,997

VIP Access (8 seats only) $12,997

3.Would you like to add seats? Please specify how many extra seats you would like to add to your access:
-Standard 4 Seats (+$1,499 per additional seat)
-Standard 8 Seats (+$1,250 per additional seat)
-VIP 8 Seats (+$1,797 per additional seat)

4.Would you like to submit your payment in 1-Payment, or 2-Payments?

1-Payments

2-Payments

5.Would you like to use your card on file with Tower Leadership?

Yes

No

6.If you would like to use a different card, please input your information below:

Today's Date:

Name on Card:

Best Contact Phone Number:

Credit Card Number:

CVV:

Expiration Date:

7.If you would like us to reach out to you to collect the appropriate payment method, please click the box below.

Please reach out to collect payment

Terms of Agreement: Fifty percent (50%) of the total amount is refundable if canceled before August 1, 2025. Cancellations after this date are non-refundable. By signing this form, I acknowledge and agree to the total amount due and the payment terms outlined herein. I understand that I am committing to make all payments on time for the 2025 Tower Impact Summit. I further acknowledge that any reproduction, distribution, transmission, or commercial use of materials provided by Tower Leadership, LLC is strictly prohibited.