Credit card authorization form

Credit Card Authorization Form

Please add your name in the form below exactly as it appears on your ID

Student Name

Last Name

hereby authorize the office of Eric Meyer DDS, Inc. to charge my credit card. This authorization will remain in effect until I have rescinded it in writing and in such time as to afford you a reasonable opportunity to act on

Date

Practice Name: Fullerton Dental Assistant School
Office Number: (714) 882-5518
Fax Number: (714)879-0754

Card Issued By:

Visa

MasterCard

Discover

American Express

Student’s Name

Authorized Charged Amount

Credit Card Number

Card Expiration Date

CVV# (3 digit code (back of card after last 4 digits of card #)

Cardholder’s Name:

Credit Card Billing Address: (Must include zip)

Please Upload Your Student ID

Choose File

Please Upload The Credit Card Holder’s ID

Choose File

Signature

Sign Here

Call Us: 714-882-5518

Credit card authorization form

Get a job in a dental office while you’re learning

We are the only school that issues certificates before graduation allowing students to get paid while attending the program.

Navigation

Courses

Contact