Credit Card Authorization Form

Field is required!
Field is required!
Name of cardholder :
This field is required
This field is required

Billing Address :

Address:
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This field is required
City :
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This field is required
States:
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Field is required!
Country:
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This field is required
Zipcode:
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This field is required
Cell Phone Number
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This field is required
Email address:
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Field is required!
Card Type :
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This field is required
Other Card Type :
Please type in
Please type in
Card Number:
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This field is required
CVV / CID
Visa, Mastercard and Discover credit cards is a three-digit number on the back,The American Express CID is on the front of the card above the account number
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This field is required
Expiration date:
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This field is required
I authorize the valid until pay off the tuition :
Your initial
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This field is required
I_( YOUR NAME ) , hereby authorize Honolulu Nails & Aesthetics Academy to charge my credit card for: (STUDENT'S NAME)
Please fill out your name and student name the boxes below :
Your Name
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This field is required
Student's Name
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This field is required
I certified that, all the given information is correct:
your signature here
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This field is required
Certified Date
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This field is required