Coaching Agreement and Credit Card Information
FAX-able Credit Card Information. Do not send sensitive information through e-mail. 

PRINT THIS PAGE AND FAX TO:
Rebecca Hanson: 561.828.3786

NOTE: This transaction will be billed on your credit card statement as Law of Attraction Resources. 
FAXing this page to Rebecca constitutes an agreement for coaching as described in this website.

First name: ___________________________

Last name:__________________________

Address:_____________________________

City:_________________________________

State/Province:________________________

Zip/PostalCode:_______________________

Country:______________________________

Phone:_______________________________

E-mail: _______________________________
(So you will get a receipt)

 

Card information:

Place
# Hours
Total
3 hours of LOA Coaching

$1200 US

Name on card: _________________________
(if not the same)

Card Number: __________________________

Card Type: Visa MasterCard AMEX Discover

Expiration date: _______Month _________Year

 

X______________________________________________________________________________ Your Signature