CREDIT CARD FORM

Credit Card Information Form

Company Name:

RSPC Act #:

Phone Number:

Fax Number:

Name on Credit Card:

Credit Card Number:

Expiration Date:

Security Code:

Billing Address:

City:

Zip Code:

State:

The Rio Plex Safety Council is authorized to charge the following:

Credit Card on File - To pay for future training/service invoices. The last four digits of the card must be included on the registration/authorization form or online registration (Extranet).

Single Use - To pay for training or services on a one-time basis. Completed registration/authorization form must be included.

Invoices - Please list Invoice Number and Amount in space provided below.

Medical - To pay for medical services on a one-time basis. Completed registration/authorization form must be included.

New Membership - Please complete the online membership application(form is at New Membership tab)

Membership Renewal

Other

Free Text

Use this space only for invoices or for single use of card.

Invoice Number/Name of Trainee - Slot 01:

Invoice Number/Date - Slot 01:

Amount (in $) - Slot 01:

Invoice Number/Name of Trainee - Slot 02:

Invoice Number/Date - Slot 02:

Amount (in $) - Slot 02:

Invoice Number/Name of Trainee - Slot 03:

Invoice Number/Date - Slot 03:

Amount (in $) - Slot 03:

Free Text

Total Amount To Be Charged:

Total Amount To Be Charged:

Free Text

All receipts are emailed. Please clearly print the email address below.

Email to send the receipt:

Card Holder E-Signature

Date:

Our educational platform provides a strong foundation of safety fundamentals that empowers a positive safety culture for preventing workplace injuries, accidents and illnesses.

Rio Plex Safety Council focuses on safety, integrity, customer commitment, respect, education, trust, teamwork, and community. “It takes a community to raise safety awareness and we are proud to be part of it”.

CONTACT US

110 S. Col Rowe Blvd/2nd St.

McAllen, TX 78501

PHONE: (956) 928-1967
FAX: (956) 618-2490

CUSTOMERSERVICE@RIOPLEXSAFETYCOUNCIL.COM

HOURS OF OPERATION

M-F: 7AM – 4PM
LAST CHECK-IN AT 2:00PM