10343 Federal Blvd. Suite J- 401,Westminster, CO 80260
Cardholders Name ____________________________________________________________________________________
Credit Card Billing Address _________________________________________________________________________
City _______________________________ State _______________________ Zip Code _________________________
Phone _________________________
Email __________________________________________________
Acct.# ______________________________________________________________________________________________
Card Expiration Date: Month _______________________________ Year ____________________________________
CCV number - Three (3) digits above your signature ________________________________________________________________
Amount to debit:
______________________ Total testing fees
______________________ (Add $20.00 - Return my report by UPS)
______________________ Add 5% - Credit or debit card service fee
______________________ Total Transaction
Cardholder's Signature (required) _________________________________________________________________________________
Date (required) ___________________________
Printed Signature (required) ______________________________________________________________________________________
Refund Policy: If your test is in progress, no refund will be received.
The cardholder will receive an email receipt referencing this debit.
