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

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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

    mailto:training@ mike Highlight

    mike Highlight