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The form captures essential participant information, cardholder details, and billing data for processing early or late registration fees. It provides a structured layout for selecting payment categories based on participant status, including students, professionals, and the general public, while outlining important submission instructions via email or fax.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/phsu-credit-card-authorization-form-2018-workshop/288686/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/phsu-credit-card-authorization-form-2018-workshop/288686.png","ImageObject",442,249,{"name":88,"@type":89},"wps_ap_test_251126_0180","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who is the credit card payment authorized for?","Question",{"text":108,"@type":109},"The payment is authorized for the Ponce Health Sciences University regarding the Puerto Rico Neuropsychoanalysis Workshop.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What are the different registration fee categories?",{"text":113,"@type":109},"Fees are divided into Early and Late options for Students, PostDocs, and Residents versus Professionals and the General Public.",{"name":115,"@type":106,"acceptedAnswer":116},"How can the completed form be submitted?",{"text":117,"@type":109},"The form can be submitted by emailing it to PRNPSAworkshop@psm.edu or by faxing it to 787-984-5507.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288686,1790043926,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","AUTHORIZATION FORM FOR CREDIT CARD PAYMENTS \nPuerto Rico Neuropsychoanalysis Workshop \nNovember 2nd and 3rd , 2018 \nImportant: Workshop will be in English \nParticipant full name: \nPhone number: \nEmail address: \n__________________________________________ \nCardholder name (as shown on card): \nCredit card number: \nCredit card type: MasterCard Visa \nExpiration date (mm/yy): \nCardholder zip code ( from credit card billing address): \nI hereby authorize Ponce Health Sciences University to charge to credit card described above the following: \nEarly fee: ā˜ $60 ( Students, PostDocs, and Residents) : \nā˜ $120 (Professionals and General Public) \n(payments on or before September 30,2018 ) \nLate fee: ā˜ $90 ( Students, PostDocs, and Residents) : \nā˜ $150 (Professionals and General Public) \n( payments after September 30, 2018) \nCost above includes: workshop for both days and Certificate provided by International Neuropsychoanalysis Society. CE Credit cost is additional and may be paid on the same date of event.. \nCredit cardholder authorized signature: Date: \nPlease submit completed form to [PRNPSAworkshop@psm.edu](PRNPSAworkshop@psm.edu) or by fax to 787-984-5507","cbCaipfHZZT58nYi","https://ap.wps.com/l/cbCaipfHZZT58nYi","pdf",1506134,"English","# Workshop Details\n## Participant Information\n## Payment Authorization\n## Fee Structure\n## Submission Instructions","[{\"question\":\"Who is the credit card payment authorized for?\",\"answer\":\"The payment is authorized for the Ponce Health Sciences University regarding the Puerto Rico Neuropsychoanalysis Workshop.\"},{\"question\":\"What are the different registration fee categories?\",\"answer\":\"Fees are divided into Early and Late options for Students, PostDocs, and Residents versus Professionals and the General Public.\"},{\"question\":\"How can the completed form be submitted?\",\"answer\":\"The form can be submitted by emailing it to PRNPSAworkshop@psm.edu or by faxing it to 787-984-5507.\"}]","PHSU Credit Card Authorization Form - 2018 Workshop | PDF",1789633780]