Secure Credit/Debit Card Transaction Form

Your card will be charged exactly $50.00

Exact Name on Card:  
Parent's Name (As it appears on court documents, if different):  
Parent's Name: We must have the name of the person who is actually taking the course. This name will be entered on the Certificate of Completion which will go into the case file.  
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:  $50.00
Expiration Date:  Month       Year
E-mail Address:  
E-mail Address: This must be a working e-mail address that you will check during the course. Instructors will use this address to communicate with you and email your Certificate of Completion.
Parent's Phone Number:  
Billing Address Zip Code:  
Card Declined? It may be that the address the bank has on record for the card or the security code is incorrect. Do not run the card more than once. Call (888) 747-5362. An instructor can assist you.
Certificate Mail Address:
Certificate City, State Zip: ,
Certificate Mailing Address: Enter the postal address where the original Certificate of Completion should be mailed. Include an apartment or lot number if necessary.
Attorney Name (if you have one):

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