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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