Beaumont Credit Card Authorization

Date
MM slash DD slash YYYY
Client ID #*
Name
First Last
Company*
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Fax
Email
Credit Card Type
- Visa
- Mastercard
- American Express
- Discover
Credit Card Account #*
Expiration Date*
Amount of Classes/Invoices*
This is to authorize ISTC to pay for safety classes using the credit card listed above. If any price discrepancies occur, your company will be notified by phone the same day of the transaction, and an edited form must be initialed next to any and all changes made in order to be processed. In order to insure proper credit to your account, please list invoices (if available) or the date of the class(es) that were taken with the name(s) of the student(s) that are being paid for below.
Click or tap the plus (+) icon to add additional students or invoices.
Student Name/Invoice Number Classes Taken/Class Date

Click or tap the plus (+) icon to add additional students or invoices.
Authorized Signature
Receipt send by:
- Mail to above address
- Email to above email address
- Fax to above fax number
CAPTCHA

Student Name/Invoice Number	Classes Taken/Class Date