ASIRT Education Abroad Trial Membership
Secure Payment Form
Order Summary:
Order Date: 12/10/18
6 Month Trial Payment:
10% discount for URMIA or FORUMEA members and Terra Dotta users. Enter discount amount $:
Please manually enter total amount of payment, including discount, if applicable. $:
Request Reports
(ex: unlimited; or
1.Tunisia, 2.Gabon, etc.):
Automatic Recurring Payment Information:
Schedule: biannually
After today's initial payment, next payment of equal value will be charged in
6 months:
Debit or Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
[What is the Card ID?]
Contact Information:
School Name:
Contact First Name:
Contact Last Name:
Address Line 2:
Phone Number:
Email Address:
Terms of Agreement:

When you select "Process Payment," you agree that you represent a school and its education abroad and/or risk management offices. Businesses or Corporations, or business travelers, are exempt from this Trial Membership. You agree to allow ASIRT to charge your credit card for 2 payments of equal value. The first payment for Trial Membership will be immediate, and the second payment, entitling you to Full Membership Status for the remainder of the year, will automatically occur 6 months from today. You agree that if you discontinue membership, you will notify before the 5th month of Trial Membership expires. You must receive written confirmation from ASIRT that your membership is voided.

NOTE: You agree that you, the organization you represent, and its constituents immediately will discontinue to use any portion of ASIRT's reports. Should you attain Full Membership Status, ASIRT will provide access to additional road safety resources for use during the remainder of the year.