Virtual Membership Credit Card Authorization Form

"*" indicates required fields

Name*

First Last

Business Name*

Email*

Cell*

Birthday - Just month and day*

Name as it appears on the card*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Card Number*

Expiration Date*

Enter as MM/YY

FOUR DIGIT CID AMERICAN EXPRESS

THREE DIGIT CV CODE OTHERS

Please read our member agreement here and agree to the statement below.

I agree that I have read, understand, and will honor all policies and information included in the Member Agreement.

By submitting this I consent to being contacted by Hera Hub and having my information (including the last four of my credit card) stored by a third party on behalf of Hera Hub