Secure Credit/Debit Card Transaction Form

Your card will be charged exactly $40.00

Exact Name on Card:  
Student's Name (if different):  
Student's Name: We must have the name of the person who is actually taking the course. If that person is different from the cardholder, please enter that person's name in the Student's Name field above. This name will be entered on the Certificate of Completion.  
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:  $40.00
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 as the primary way of communicating with you.
Student's Phone Number:  
Card Billing Address 1:  
Card Billing Address 2:  
Billing City, State, Zip Code:  ,
Card Declined? It may be that the billing address or the card security code is incorrect. If your card is declined and you are sure everything is correct, call (888) 747-5362. An instructor can assist you.
Certificate Mail Address:
Certificate City, State Zip: ,
Certificate Mailing Address: Enter the address where the Certificate of Completion should be mailed if it is different from the billing address. Include an apartment or lot number if necessary.
Attorney Name (if you have one):

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