NAME AND BILLING ADDRESS(as on credit card statement if paying by credit card)
Social Security# required
Present Total Household Income
Number of Dependents
Are you employed at this time? YesNo
Is your spouse employed at this time? YesNoNot Applicable
Payment As You Go - $265.00 + $35.00 s/h - $40.00 per month for as long or as little needed to complete the program - US residents only!
None of these payment plans fit my needs. I would like to discuss further options.
I PREFER TO PROVIDE PAYMENT INFORMATION VIA PHONE
Type of Credit Card VisaMastercardDiscover
Debit Card Debit Card with Visa/Mastercard Logo Only!
Credit Card #
Debit Card #
Signature:_______________________________ (required by person named on credit/debit card)
SUBTOTAL OF ORDER
MINUS ANY DISCOUNT DEDUCTION