Credit Card Authorization Form

You have the option to pay your invoice online. Should you prefer that we process your card at the office then please complete and return the Credit Card Authorization form below.

 

CREDIT CARD AUTHORIZATION FORM

I hereby authorize Regina Erhart Fasold, owner of FASOLD GLOBAL CONSULTING Inc. to charge my credit/debit card for the amount shown for services or programs as noted in the Coaching Agreement until I terminate that authorization in writing.

Client Name:

Name on Card:

Billing Address:

City/State/Zip:

Email:

Card Number:

Expiration Date MM/YY:

Security Number on back of card:

Card Type:       _____  MasterCard      _____ Visa      _____ American Express

Authorized Signature:

Date:

Please return this form prior to the first coaching session to: info@reginafasold.com We guarantee that your information is safe and confidential. Your credit card statement will show a charge from “International Leadership Coaching.” Should you have any further questions please contact us immediately. 

 
FASOLD GLOBAL CONSULTING
Office: 321-221-1106
Email: info@reginafasold.com