WIAL CREDIT CARD PAYMENT

Name *

First

Last

Email *

Company/Organization/Affiliate *

Amount you are paying *

$1,000
$2,000
$4,000
Other

Other Amount

If selected "Other" IF YOU DID NOT SELECT "OTHER" LEAVE THIS BLANK!

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please note: It is important to ensure that you select the correct country.

Remarks for Reference

Total

$0.00

Please make sure this number matches the amount you are paying.

Personal Data *

Personal Data *

You acknowledge and agree that we may use your personal information consistent with our privacy policy and that we may share your information with the international WIAL organization and other WIAL Affiliates. Once you are certified as a coach or partner, you authorize us to post your contact information, and the photo, company name, title, website address, curriculum vitae or brochure, affiliation, credentials, bio and other similar information that you provide to us on WIAL directories and in other WIAL materials or communications, listing you as a coach or partner, as applicable.

PAYMENT TO WIAL THROUGH CREDIT CARD