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Credit
Card Information
Credit Card Type: __ AMEX __ Discover __ MasterCard __ VISA
Amount to be billed: $____________________
Card Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Security Code (last 3 digits on back of card): ___ - ___ - ___
Expiration Date: ____/____/____
Name as it appears on Card: ________________________________________________
Credit Card Billing Address (where you receive your credit card statements):
Street: ________________________________________________
City: ______________________ State: _____ Zip Code: ___________ Country: ________
Organization Name: ______________________________________________________
Daytime Phone: __________________________________________________________
Fax: __________________________________________________________
Email Address: __________________________________________________________
Workshop Attending: _____________________________________________________
Number of Registrants: ______________
Names of Registrants: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Authorization
I hereby authorize 21st Century Schools to charge the amount shown above to the card specified above.
I agree to pay the above credit card charges in accordance with the Card Issuer Agreement.
I understand that 21st Century Schools will apply a charge back fee to my account ($50.00US as of the
time this is written), if I initialize a charge back with my credit card issuer, to reverse payment without
21st Century Schools permission of any of the charges authorized on this form, and I agree to pay this
fee if this occurs.
Cardholder Signature: ______________________________ Date: ___________
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