Family & County Mediation Certification Courses
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IMPORTANT:
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- Payments processed after 6:00 p.m., and on weekends, will not be posted until the following business day.
- By completing this form, you are authorizing CPLS to use this card to pay for the legal services being provided to you, person, and/or business entity listed in the Attendee Name field of this payment form.
- All payment amounts are processed in U.S. dollars.
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Attendee Name:
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| Payment Date:
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04/25/24
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| *Attendee Name:
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| County Mediation Certification Course $495.00: *Please select one of the options below. We will contact you to confirm your specific date selection. |
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| March 30,31, & April 1, 2023: |
Enter "1" to register for this option. |
| June 8,9,10, 2023: |
Enter "1" to register for this option. |
| Sept 14,15,16, 2023: |
Enter "1" to register for this option. |
| Family Mediation Certification Course $895.00: *Please select one of the options below. We will contact you to confirm your specific date selection. |
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| Feb 23,24,25, & March 2,3, 2023: |
Enter "1" to register for this option. |
| May 18,19,20, & 26,27, 2023: |
Enter "1" to register for this option. |
| August 10,11,12, & 18,19, 2023: |
Enter "1" to register for this option. |
| Total $: |
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Credit Card Information:
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*Card Type:
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*Card Number:
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*Card Expiration
Date:
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MMYY
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*Card ID (CVV2/CID) Number:
[What is the Card
ID?] |
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*Cardholder Name
(Name as it appears on card):
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| *Card Billing Address:
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| *Card Billing City: |
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| *Card Billing State: |
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| *Card Billing Zipcode: |
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| *Email Receipt To: |
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*I agree to the Terms and Conditions:
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By submitting this form, you hereby authorizes CPLS, P.A. to charge against said card the following one time charge for legal services and/or costs provided to and/or on behalf of the above client. Your agreement to pay the Clients fees and costs does not authorize CPLS, P.A. to disclose any information to him/her about the Client without the Clients approval. |
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CPLS, P.A.
201 E. Pine Street, Suite 445, Orlando, FL 32801 407.647.7887 Tel. 407.647.7887 Fax
www.cplspa.com
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