CEU Registration

Safe Harbor Counseling
Registration and Payment Authorization Form

Name of CEU presentation(Required)

Your registration will be complete once this form and payment are received.

Participant Name(Required)

License #

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Authorization(Required)

I authorize Safe Harbor Counseling to charge the credit card

Credit Card Charge Authorization Amount(Required)

Account Type(Required)

VISA

MasterCard

Discover

Amex

Cardholder Name(Required)

Credit card number(Required)

Exp Date (MM/YYYY)(Required)

CCV(3/4 Digit # on back of card)(Required)

Billing Address(Required)

Street Address City State ZIP Code

Authorization - Check(Required)

I will mail a check to Safe Harbor Counseling, 76 S. Main St. Ste A, Sugar Grove, IL 60554

Check Amount

Signature(Required)

Date(Required)