AP Seminars Credit Card Payment 2019
Submission of this form does NOT immediately charge your card. That will be done manually by AP Seminars once this form is received. Your payment will be confirmed by e-mail.
1. LAST Name of Participant *
Your answer
2. FIRST Name of Participant *
Your answer
3. Primary Phone (FORMAT, PLEASE: XXX-XXX-XXXX) *
Your answer
4. Primary e-mail *
Your answer
Subject registered for *
5. What is it you want to pay for? *
Check all that apply. We are now in the early registration period (through May 10, 2019). Write total for all checked items in Item #8.
Required
6. If buying lunch, do you have any dietary restrictions?
Use only if you chose "Lunch" in #5
7. Explanation of "Other" from item #5
Please be as specific as possible
Your answer
8. . What dollar payment is being made with this form? *
Total of checked boxes in item #5 (Double check that this matches the total on your registration summary)
Your answer
9a. Credit Card Number (Visa, MasterCard, Discover, Am Ex; Format as shown) *
VERY IMPORTANT: FORMAT WITH DASHES AS SHOWN Visa, MC, Disc: XXXX–XXXX–XXXX–XXXX; AM EX: XXXX–XXXXXX–XXXXX)
Your answer
9b. Credit Card Expiration Date *
IMPORTANT: FORMAT AS FOLLOWS: MM_YY (not MM/YY)
Your answer
9c. Credit Card 3-digit Security Code (3-digit code on back) *
Your answer
10. Comments?
Your answer
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