Credit Card Information * Card Type: MasterCard VISA Discover AMEX Other Cardholder Name (as show on card): * Card Number * Expiration Date (mm/yy): * CVV code * Cardholder ZIP Code * (from credit card billing address): Authorization Agreement * By clicking the box, I authorize Heather Land, SHEchiatry Women's Empowerment Specialist, to charge my credit card above upon scheduled coaching appointment. I understand that my information will be saved to file for future transactions on my account. Thank you!
