Secure Credit/Debit Card
Transaction/Registration Form

Your card will be charged exactly $995.00

Please call (888) 747-5362 if you have any questions
or to make other payment arrangements.

Exact Name on Card:  
 2nd Trainee:  Included in fee
2nd Trainee: If you are going to be attending as a team with a second person, please provide that person's name. Course fee is the same for one or two.  
Card Number:  
Card Security Code:  
Card Security Code: Last 3 numbers on signature strip on back of Visa, Mastercard or Discover. 4 Numbers on right above account number on front of American Express.
Exact Charge Amount:  $995.00
Expiration Date:   Month     Year
E-mail Address:  
E-mail Address: This must be a working e-mail address that you will check during the time leading up to and after the course. Trainers will use this address as the primary way of communicating with you and supporting you after you have completed your training.
Contact Phone Number:  
Card Billing Address 1:  
Card Billing Address 2:  
Billing City, State, Zip Code:  ,
Card Declined? It may be that the billing address, expiration date or the card security code is incorrect. If your card is declined and you are sure everything is correct, call (888) 747-5362. We can help.
Contact Mail Address:
Contact City, State Zip: ,
Contact Mailing Address: Enter a mailing address if it is different from the billing address. Include an apartment or lot number if necessary.

Contact us by email at
Contact us by phone at (888) 747-5362
Copyright 2002, 2018 Positive Divorce Resolution, Inc.
Last edited October 10, 2018 by Robert J. Perchalski, Ph.D.