7 Safety Training LLC
Credit or Debit card authorization form
To process your credit card please complete ALL HIGHLIGHTED areas
Card Holder Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Company Name (only if it’s a company credit card):
First Name
Last Name
Card Holder Billing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Card (Must check ONE box):
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VISA
MASTERCARD
AMEX
DISCOVER
CVV2 #
*
Card No:
*
Card Exp. Date:
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Month/Day
TOTAL Amount Authorized to Charge
*
If payment provided if for more than one training event/participant, see below for breakdowEvery credit card transaction has an additional 3.99% charge.
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I authorize 7 Safety Training LLC charge the above credit card for the authorized amount. I have read and reviewedcancellation and deposit policy and agree to the terms as written. I understand that failure to providethree (3) days advance notification of registration cancellation may result in forfeiture ofdeposit payment (s). Further, no course completion material (s) will be released until ALL accountbalances have been paid in full.
Current Date:
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Month
-
Day
Year
Card member acknowledges receipt of goods and or services in the amount of the total shown hereon andagrees to perform the obligations set forth by the card member’s agreement with the issuer.
Card Holders’ Signature:
7 SAFETY TRAINING LLC
Office 929-461-5203 • Email.: 7safetyny@gmail.com • www.7safetyny.com 67-21 Roosevelt Ave. Woodside, NY 11377
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