EmailMeForm
Pay Simple Automatic Payment Application
Thank you for choosing the Academy of Creative Coaching. Please complete the application to set up your tuition payment plan or to register for the Mastermind Experience. If you have any questions, contact us at:
800-861-8490
info@academyofcreativecoaching.com
Name
First
Last
Today's Date
MM
/
DD
/
YYYY
Email
Phone
###
-
###
-
####
Payment Preference
Please select
One full payment
6 month payment plan
9 month payment plan
12 month payment plan
Other
If other, please specify:
Program Type (Early-bird discounts will be automatically deducted, as applicable)
Please select
Weekend Intensive - Certification Only - $1997
Weekend Intensive - Certification & Credentialing - $2597
66-Hour Coach Training Program - $4200
133-Hour Coach Training Program - $7500
Self-Paced Coach Training Program - $2100
Mastermind Experience - $1250 (ACC Grad)
Mastermind Experience - $2150 (Non-ACC Grad)
If other, please specify:
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Card Type
Please select
Visa
Master Card
American Express
Discover
Card Number
CVV2 Code
CVV2 Code is the 4 digit number printed above your American Express Card account number on the front of your card or the last 3 digits of the number located on the back of your Discover, MasterCard, or Visa card.
Expiration Date
MM
/
YYYY
Billing Zip/Postal Code
Preferred day of the month for automatic withdrawal:
Automatic Withdrawal Approval
By typing and signing my name below and submitting this form, I authorize automatic withdrawals to be made from the credit card account listed above through Pay Simple per this agreement between myself and the Academy of Creative Coaching to cover the costs of tuition. I understand that it is my responsibility and commitment to pay the amount listed above in full.
Refund Policy
3-Day Right to Rescind: Students have the right to rescind their enrollment agreement and receive a full refund of any amounts paid to the Academy of Creative Coaching, which they must exercise in writing within three (3) business days from the day they submit the purchase. You must deliver a written rescission of the enrollment agreement to the Academy of Creative Coaching within such 3-day period, or if the rescission is mailed, it must be postmarked on or before the last day of the 3-day period.
If withdrawal occurs after the 3-day period, monies paid to the Academy of Creative Coaching can be applied to future enrollment in a course.
Please print your name below:
Signature
Clear