Qualified Mentor Payment Information

If submitting manually, please make one (1) copy and staple to the front of the first copy of your application. This copy will be retained in the HTP office. This form is not necessary if submitting digitally.

Billing Information:

Last Name:	First Name:	Middle Name or Initial:

Address:

City:	State/Province:	Zip/Postal Code:

Country:

Email Address:

Qualified Mentor Application Fee - $50

Payment information, Choose one of the following:

Enclosed is a check or money order for $50.00. Make check payable to HT Certification.

Please charge my credit Card:

Choose one: VISA M/C Discover

Card Number:

Expiration Date:	Three digit safety code:

Signature:

By checking here, I am providing my electronic signature approving all the information entered above.

Office Use Only: Auth #:	CC Order #:

© Copyright 2008 - 2010 Healing Touch Program HTP-942-E	Rev 05.30.11

Margaret Nies

2011-05-31