Non-ASEA Education Credit Payment Form

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This field is for validation purposes and should be left unchanged.

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Primary Phone*

Primary Phone Type*

Alternate Phone

Alternate Phone Type

National ID #*

Event Discipline*

Title of the Event*

Event Venue Location*

(e.g. Resort Name or City and State)

Name of Sponsoring Organization*

(i.e. USSA, CSIA, NZSIA, etc.)

Address of Sponsoring Organization

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sponsoring Organization's Phone*

Event Dates*

Event Description*

Who Approved your Event?*

Please provide who in the office granted your request. ( This cannot be an examiner, ed-staff member, etc)

Attendance Verification Form

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Please add your completed Attendance Verification Form here. You may also email the form to submissions@psia-c.org or by snail mail to the Central Office at P.O Box 2144, Frankfort, MI, 49635.

Event Credits

Participants who select more than their pre-approved credits will be refunded the cost of the additional credits minus an administrative fee. If you have not yet gained approval for your Non-ASEA event please exit this form now. All Non-ASEA request more be made through the Non-ASEA Request Form.

Product Name*

Total

Payment Method*

Credit Card

Check by Mail

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name