EmailMe Form - Payment Authorization Form

Name *

First Last

Organization *

Payment/Reservation Type *

Recurrence *

Single Payment / Pay-In Full

Billing Plan (Special Program or Retreat)

Weekly

Monthly

Authorized Amount *

$ Dollars . Cents

Credit/Debit Card Number *

Card information will be delivered and processed via Authorize.net safe encrypted merchant.

Expiration Date (MM/YY) *

Security Code *

(3 Digits Back Visa/MasterCard/4 Digits Front for Amex)

Card Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Safe & Sound *

I understand my information is safe and will NEVER be shared or disclosed. Information provided in this form will be delivered in confidentiality to support@holisticauthority.org and payment will be processed via safe encrypted merchant processor.

Payment Authorization *

I provide the authorizing signature. Please process payment for authorized amount only.

I am authorized to approve this transaction. Please process payment for authorized amount only.

Picture ID Upload

Your Message or Special Instructions (Optional)