Credit Card Form for Seminar use this one by we9mj6AB

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									                    C         havis &            A         ssociates, LLC.

             Seminar Registration and Payment Form
I wish to register for the Seminar titled: How to Survive & Thrive in today’s .Economic
Conditions

Name:______________________________ 2nd Person:_____________________________

3rd Person___________________________ 4th plus:________________________________

I understand the fee for the first person is $300.00, 2nd $200.00 and $100.00 for any additional
People.

I authorize Chavis & Associates, LLC. To charge $__________________ on my credit card for
the
Seminar.



Credit Card Information:

Client Name as on the Card:_______________________________

Bank Name:____________________________________________

Billing Address on Card: __________________________________

Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Expiration Date: _ _ _ _ Number on back: _ _ _

Amount to be Paid:__________ Plus Tax where applicable _____

E-Mail Address (to send confirmation): _________________________


_______________________________________
    _______________________________________

Company Name                                  Authorized Signature
Date

								
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