CHGCD Form

Thank you for Registering. Please fill out the form below if you would like to have us charge you via credit card authorization.

Name of Cardholder (as it appears on the card) *

Email Address *

Billing Address of Cardholder *

City/State/Zip *

What is this payment for? Please note the class, event, etc you are paying for. *

Card type: *

Master Card

Visa

American Express

Amount of transaction authorized $ *

Credit Card Number *

Expiration *

3/4 digit pin (back of card) *

Phone *

Signature (Writing out your full name below authorizes and agrees to the amount on this transaction) *