(associated with credit card)
Contact Phone #
Email address (REQUIRED)
Please enter the txt into the box, then submit
Credit Card Type:
Credit Card Number
3 or 4 Digit Security Code on back:
I hereby authorize charges to my card in the amount listed here.
After you SUBMIT your order we'll followup within 24 hours after we've processed your renewal/payment.
Completing this form will NOT automatically charge your card. All registrations are manually processed by staff. If you need to change something just call the office at 614.883.1739 or email email@example.com. If it's after hours or weekends just leave a message and we'll check with you before processing any charges.
Invoice #, if any
Use format of 555444222 -
no spaces or hyphens
Professional Medical Education Association, inc
This is a secure web page (SSL) to accept credit card payments for invoices or other charges for both
Laser Training Institute
, and the
National Council on Laser Certification