HAGGAI INSTITUTE - Advancing Leadership Skills Since 1969
17-May-2012
 

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  		• Please enter your card number WITHOUT spaces or dashes—e.g. 1234123412341234.
  		• Your card EXPIRATION DATE should appear as four numbers—e.g. September 2004 is 0904.

    Credit Card Details:
    Participant Name:    
    Card Holder's Name:    
    Haggai ID:    
    Session No.:    
    Credit Card Name:   
    Credit Card Number:    
    Card Security Code:      The card security number will usually be a 3- or 4-digit number printed on the back of the card in the signature area, for most cards, and will usually follow the full card number. For Amex cards, the number is a 4-digit number printed above and to the right of the embossed number on the front of the card.
    Exp Date (MMYY):    
    Note: Please specify amount in US Dollars only ($)
    Charge Amount:  $
    Credit Card Billing Address:
    Country:
    Street Address: 
    City/Town: 
    Zip/Postal Code: 
    E-mail: 
    Telephone: