FiberTrain - Secure Information and Credit Card Authorization Form

Secure Information and Credit Card Authorization Form
Only VISA and MASTERCARD accepted at this time

Please do not use this form until the information is requested by FiberTrain, following mutual agreement on specifics and costs of training to be provided.

This form has been provided as a more secure and accurate way of obtaining sensitive personal and credit card information than providing it over the telephone. The actual credit card transaction is a manual process that will be performed later, after confirmation of training details.

Full Name:*

(Requestor or point of contact)

Email:*

Company /
Command:

(Leave blank if not applicable)

Address:*

Phone:*

FAX:

Other:

Number of Students:*

Requested Training Start Date:* (Subject to change until final payment and confirmation)

Training Location for local classes is the classroom inside the Norfolk Wire & Electronics store in Virginia Beach, VA. If special arrangements have been made to hold your training in a different location, please enter it here:

Course(s) requested:

NO-
YES-
Add Optional Basic Fiber Optics Installer Tool Kit ($300) with course?

Remarks:

Credit Card Info (VISA or MASTERCARD only):

Type of Card:*

Name on Card:*

Card Number:*

3-Digit CCV Number from Back:*

Expiration:*

Month- Year-

Amount *
Authorized:

$(USD) Amount you are authorizing. If amount is determined to be incorrect for any reason, you will be contacted with a corrected total for approval prior to charging account.

(*=Required Entry)

NOTE: This is a secure page under the following conditions....

The link address of this page is https://fibertra.ipower.com/secureinfo.htm and starts with "https" instead of just "http". Click on this link if unsure or to reload page.
A closed lock or key icon, such as one of these depending on your browser, is displayed in your browser status bar, usually near one of the upper or lower corners. If the status bar is not enabled, the icon will not appear. To enable the Status Bar in Internet Explorer, for example, click View, and then click to select Status Bar. Double-clicking on the lock or key icon should display the security certificate for the hosting server of this website, iPowerWeb.com, authenticated by The USERTRUST Network.

Contact FiberTrain Corporation™ to accomplish your installer training needs at , or email

Full Name:*	(Requestor or point of contact)
Email:*
Company / Command:	(Leave blank if not applicable)
Address:*
Phone:*
FAX:
Other:

Type of Card:*
Name on Card:*
Card Number:*	3-Digit CCV Number from Back:*
Expiration:*	Month- Year-
Amount * Authorized:	$(USD) Amount you are authorizing. If amount is determined to be incorrect for any reason, you will be contacted with a corrected total for approval prior to charging account.

Email decrypt_and_echo(1) with questions or comments about this web site. Copyright © 2005 by FiberTrain Corporation™. Last modified: 12/04/08.

Email with questions or comments about this web site.
Copyright © 2005 by FiberTrain Corporation™. Last modified: 12/04/08.