Clear Impact Consulting Group, Inc. is hereby authorized to charge monthly to the following credit card in the amount shown for services until terminated in writing. Please send this authorization to the address below—Thank You!

                                     CREDIT CARD INFORMATION

Client Name:     __________________________________________________________

Client Address (as used for credit card billing):  ___________________________________

City, State, Zip or Postal Code: _______________________________________________

Name on card: ___________________________________________________________

Credit Card #:__________________________________ Exp Date: MM/YY __________

Amount $:_______________________________________________________________

Card Type:  Please circle one:      MasterCard    Visa    Amex

Authorized Signature    ________________________________    Date _______________

E-mail Address (please print carefully): _________________________________________

Please mail completed form to PO Box 1139, Boulder, CO 80306, USA, or fax to 509/692-8297

To see a copy of the Coaching Intake Packet, click here.