HTA Payment Information Form

Mahalo for completing our Registration Form.

***For HTA members in good standing who selected the option to be billed for the registration fees, please disregard the form below.  You will be billed shortly.  Should you have any further questions/concerns, please feel free to contact our office at 808-833-6628 or accounts@htahawaii.org.

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) *

If you are human, leave this field blank.