17th Annual Pain Medicine Meeting November 15-17, 2018 / JW Marriott / San Antonio, CREDIT CARD AUTHORIZATION FORM In to charge your credit card and in accordance with the security measures taken by credit card companies, please fill in the following form and return. Please send this sheet by fax or email scan to the attention of: Heidi Perret ASRA Marketing Coordinator Fax: 856-589-7463 heidi.perret@ajj.com Authorization for Credit Card Charges Name of company: We authorize ASRA to make the charge of: (US currency only) $ For the following services: For meeting: Credit card details to be charged: AMEX VISA MC Number: Expiration date: / Security Code Name of card holder: Address: (as per credit card records): City: State: Zip Code: Country: Telephone number: - - Email Address for receipt: Signature of card holder: Date: / /
17th Annual Pain Medicine Meeting November 15-17, 2018 / JW Marriott / San Antonio, CREDIT CARD AUTHORIZATION FORM In to charge your credit card and in accordance with the security measures taken by credit card companies, please fill in the following form and return. Please send this sheet by fax or email scan to the attention of: Heidi Perret ASRA Marketing Coordinator Fax: 856-589-7463 heidi.perret@ajj.com Authorization for Credit Card Charges Name of company: We authorize ASRA to make the charge of: (US currency only) $ For the following services: For meeting: Credit card details to be charged: AMEX VISA MC Number: Expiration date: / Security Code Name of card holder: Address: (as per credit card records): City: State: Zip Code: Country: Telephone number: - - Email Address for receipt: Signature of card holder: Date: / /
2018_pm_booking_form.docx