Course Registration (Page 2 of 2) in pdf

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Arnold a nd B lema S teinberg M edical S imulation C entre

CREDIT C ARD

3575 P arc A venue S uite 5 640

AUTHORIZATION F ORM

Montreal, Q C H 2X 3 P9

Date

Customer I nformation

Company N ame

Event n ame/dates

Contact N ame

Contact T itle

Address

City

State

Postal/Zip

Country

Telephone

Fax

Credit C ard I nformation

Card T ype □ Visa

□ Master Card

□ AMEX

Cardholder n ame

Cardholder t elephone ( if d ifferent f rom a bove)

Billing a ddress ( if d ifferent f rom a bove)

City

State

Postal/ z ip c ode

Country

Card n umber

Expiry d ate

Amount t o b e c harged

Cardholder s ignature

By s igning t his f orm, y ou a uthorize t he A rnold a nd B lema S teinberg M edical S imulation C entre

to c harge a bove-‐referenced c redit c ard f or t he a mount s pecified.

For s ecurity r easons, p lease d o n ot s end y our c redit c ard i nformation e lectronically

( email, i nstant m essage, s canned d ocument, e tc.)

Fax: ( 514) 3 98-‐5497

Mail o r d rop-‐off:

Arnold a nd B lema S teinberg M edical S imulation C entre

c/o C indy B olduc

3575 P arc A venue, S uite 5 640

Montreal, Q uebec H 2X 3 P9

Course Registration Page 2