(associated with credit card)
Contact Phone #
Email address (REQUIRED)
Confirm Email
or Requests?
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Credit Card Type:
Amount Authorized:
Credit Card Number
Cardholder Name
Expiration Date
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 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
the Laser Training Institute, and the National Council on Laser Certification