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["Credit Card Authorization Form"]
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["Cardholder Name:"]
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["Billing Address:"]
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[null,"City:",null,null,"State",null,"Zip Code"]
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["Credit Card Type:",null,"Visa","MasterCard","Discover","Amex"]
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["Credit Card Number:",null,null,null,"Expires:",null,"Card ID #"]
[null,null,null,null,null,null,"3 or 4 Digits on Back of Card"]
["Amount to Charge:",null,"(USD) $",null," This should be for the total amount of the class"]
[" or classes, if your are paying for more one class or more than one person"]
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["I authorize Nevada Defensive Training, to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement."]
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["Cancellations REQUIRE a minimum 48 hours notice.  You card will not be charged, subject to Nevada Defensive Training's cancellation policy available here. "]
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["A valid credit or debit card is required to hold your spot for instruction. No shows forfeit the ENTIRE tuition and you are not invited back. On the morning of instruction you can pay the tuition by cash, check, money order, or credit card on file."]
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["Cardholder - Sign, Date, & Print Name"]
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["Signed:"]
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["Dated:"]
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["Name:"]
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["Once you have filed out everything, click on the Submit button and it should email it to nvdefense@att.net. You must enable \"macros\" for it to function (I guarantee it does not contain a virus). If it does not; you can manually email it or text a picture to 775-636-5261. "]