Payment Authorization for Full-Day Training Workshop

Please complete the information below to approve the use of your credit card for payment of the full-day team training workshop. Please note, this full-day workshop will take place at Identity Dental Marketing's office in Bloomingdale, IL. Address will be provided prior to workshop. Investment of $1,500 per attendee paid to Identity Dental Marketing does not include travel or lodging.

Full Name

Business Name

Billing Address

Phone

Email

Cardholder Name

Card Number

Expiration Date

CVV
4 digits on front of AmEx or 3 digits on back of MC, Visa, or Discover

Are you a current client of Identity Dental Marketing?

Yes No

How many team members will be attending?

Name of Attendee

Job Title

What are the names and job titles of the rest of the attendees? (if applicable)

Please list any food allergies you or your attendees have. (if applicable)

I authorize Identity Dental Marketing to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this form.

Electronic signature
Please click in the box, then draw your signature.

Clear

Please Note:

If your information changes, it is your responsibility to update this form.