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Credit Card Payment Form

Workshop Title: Date of Workshop:
How did you hear about this training?:
Information about Participant Attending Workshop:
Last Name: First Name:
Job Title:
Email:
Name of Organization:
Phone: Cell:
Address: City: State: Zip:
Providence: Country:
Will additional participants be attending the workshop? If so, please provide their information below:
Participant #2
Last Name: First Name: Cell:
Job Title: Email:
Participant #3
Last Name: First Name: Cell:
Job Title: Email:
Participant #4
Last Name: First Name: Cell:
Job Title: Email:
Participant #5
Last Name: First Name: Cell:
Job Title: Email:
Credit Card Information (must match monthly statement information):
Name listed on credit card:
Credit Card Type (select one): VisaMasterCardDiscoverAmerican Express
Credit Card 16-Digit number: Security Code: Exp. Date
I give OEC² Solutions, LLC permission to run my credit card for the amount listed below Date:
Please list how you would like your name to appear on your badge if different from the name(s) listed above:
Do you or anyone attending this workshop have any food allergies? If so, please list allergies below:
Workshop Payment Information:
Qty Name of Workshop Workshop Price (Qty x Workshop Price)
    GRAND TOTAL*


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Odette Christie
OEC² Solutions, LLC
832-234-4207
ochristie@oec2solutions.com