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TRILOGY HSE I ____________________________ authorize TRILOGY HSE to charge my credit card for the PHTLS Course. (NAME) PHTLS Course Date: May 31 - June 1, 2016 E-Fax: (866)847-9802 E-Mail: training@trilogyhse.com (DO NOT MAIL) AMOUNT $150 CREDIT CARD TYPE Visa Mastercard American Express CREDIT CARD # ___________________________ CARD CV2 # ___________________________ EXPIRATION DATE ____________________ NAME ________________________________________________________________ E-mail Address ________________________________________________________________ BILLING ADDRESS ________________________________________________________________ ________________________________________________________________ BILLING ZIP CODE ____________________ NAME ON CREDIT CARD _______________________________________ (As it appears on card) Cancellation/Rescheduling Policy: Training Classes - I understand that I am registering/enrolling in a class with limited seating. I understand that I will receive no refunds if I should cancel my registration or not show for class. ____________________________________ __________________ SIGNATURE DATE TRILOGY HSE | POB 173508 | TAMPA, FL 33672 | (813)567-1099 | training@trilogyhse.com

TRILOGY HSEtrilogyhse.com/wp16/wp-content/uploads/2016/phtls/phtlstampajunereg.pdfTRILOGY HSE I _____ authorize TRILOGY HSE to charge my credit card for the PHTLS Course. (NAME) PHTLS

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Page 1: TRILOGY HSEtrilogyhse.com/wp16/wp-content/uploads/2016/phtls/phtlstampajunereg.pdfTRILOGY HSE I _____ authorize TRILOGY HSE to charge my credit card for the PHTLS Course. (NAME) PHTLS

TRILOGY HSE

I ____________________________ authorize TRILOGY HSE to charge my credit card for the PHTLS Course. (NAME)

PHTLS Course

Date: May 31 - June 1, 2016

E-Fax: (866)847-9802 E-Mail: [email protected] (DO NOT MAIL)

AMOUNT $150

CREDIT CARD TYPE Visa Mastercard American Express

CREDIT CARD # ___________________________

CARD CV2 # ___________________________

EXPIRATION DATE ____________________

NAME ________________________________________________________________

E-mail Address ________________________________________________________________

BILLING ADDRESS ________________________________________________________________

________________________________________________________________

BILLING ZIP CODE ____________________

NAME ON CREDIT CARD _______________________________________ (As it appears on card)

Cancellation/Rescheduling Policy: Training Classes - I understand that I am registering/enrolling in a class with limited seating. I understand that I will receive no refunds if I should cancel my registration or not show for class.

____________________________________ __________________ SIGNATURE DATE

TRILOGY HSE | POB 173508 | TAMPA, FL 33672 | (813)567-1099 | [email protected]

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