AP Seminars Credit Card Payment 2020
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 *
2. FIRST Name of Participant *
3. Primary Phone (FORMAT, PLEASE: XXX-XXX-XXXX) *
4. Primary e-mail *
Subject registered for *
5. What is it you want to pay for? *
Check all that apply. We are now in the Early Bird Registration Period. Write total for all checked items in Item #8.
Required
6. Explanation of "Other" from item #5
Please be as specific as possible
7. 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)
8a. Credit Card Number (Visa, MasterCard, Discover, Am Ex; FORMAT WITH DASHES AS SHOWN BELOW) *
VERY IMPORTANT: FORMAT WITH DASHES AS SHOWN Visa, MC, Disc: XXXX–XXXX–XXXX–XXXX; AM EX: XXXX–XXXXXX–XXXXX (not XXXXXXXXXXXXXXXX)
8b. Credit Card Expiration Date *
IMPORTANT: FORMAT AS FOLLOWS: MM_YY (not MM/YY)
8c. Credit Card 3 or 4-digit Security Code (code on back of card) *
9. Comments?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy