test page This form is z Devra’s Test form 2017 zzz Devra's Test form 2017 Please fill in the form below to register and pay for bridge classes with Leslie and Charlie. Name* First Last Email* Enter Email Confirm Email Primary Phone*Secondary PhoneoptionalBilling Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ClassesPlease select classes below.BEGINNER LEVEL Beginner test purchase INTERMEDIATE LEVEL Intermediate test purchase - 1 Intermediate test purchase - 2 Intermediate test purchase - 3 Intermediate test purchase - 4 ADVANCED LEVEL Advanced test purchase - 1 Discount Total cost of classesThis field is the sum of the cost of all classes selected. If this number is not greater than 0, the submit button will not show. See the form setting for this conditional logic.Make-Up Credits to apply to total?Makeup Credits are distributed in class by Leslie and Charlie. Each pass is a credit for a class which was already paid for, but missed. Coupons expiring 3/1/17 can only be applied towards the Winter classes. They can also be used to play in the Wednesday game. If you are unavailable to use them, you may give them to a friend. They are transferable. Coupons must be used by the next UNPAID class or session available. A maximum of two coupons can be used towards a future class. Any other coupons you might have can be used in the student game or given to a friend.Do you have Makeup Credits to be Applied?YesNoNumber of Make-Up Credits0 Make-up Credits1 Make-up Credit2 Make-up CreditsPlease enter the number of makeup credits you wish to apply to this purchase. You MUST hand in these credit slips on the first day of class.Expiration Date of First Make-Up Coupon* Date Format: MM slash DD slash YYYY Expiration Date of Second Make-Up Coupon* Date Format: MM slash DD slash YYYY Will you be missing a class?If you know in advance that you will be missing a class(es), you may deduct the value of that class from the total to be paid today. You must list the date(s) of your expected absence(s) below. A maximum of two credits will be applied for dates you will miss.Will you be missing a class?YesNoNumber of classes you will miss*0 missed classes1 missed class2 missed classes3 missed classesPlease enter the number classes that you will be missing from the above registration.Date of first class you will miss* Date Format: MM slash DD slash YYYY Date of second class you will miss* Date Format: MM slash DD slash YYYY Date of third class you will miss* Date Format: MM slash DD slash YYYY Late RegistrationAre you registering late? Is it less than 24 hours before your class starts?Registration submitted less than 24 hours before the start of class will incur a $25 late fee. No late fee for Beginner Part 1 students - exempt.YesNoLate Fee Price: $0.01 PaymentGrand Total $0.00 Cost of all classes, less any credits.How would you like to pay?Credit CardPayPalCredit Card DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name PayPalWhen you click the Register and Pay button, you will be transferred to the PayPal website for payment. After successful payment, you will be transferred back to the bridgeteacher.com site.NameThis field is for validation purposes and should be left unchanged.