One Time Payment

Welcome! This form should be used only in special situations for payments not easily handled by our other forms. Please do not use this form unless our staff specifically directed you here. Thank you!

Name(Required)

Please enter your first and last name.

First Last

Email(Required)

Please enter your email address.

Payment Information

Payment Amount(Required)

Please enter the payment amount here.

Purpose of Payment(Required)

Please state the reason for the payment (e.g., balance due).

Total

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Payment(Required)

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

International Neuropsychological Society • ATTN: Neurology Admin./INS 175 N. Medical Dr., 5th Floor, Salt Lake City, Utah 84132, USA • 801-487-0475 • ins@the-ins.org