NCLC LASER CERTIFICATION EXAM ORDERING FORM
This form is solely for the use of authorized NCLC proctors.

Authorized Proctor Name

Email Address

Address for Credit Card

Choose Type of Exam

Certified Aesthetic Laser Operator - CLOA Certified Laser Hair Removal Specialist - CLHRS Certified Medical Laser Safety Officer - CLSO/M Certified Laser Repair Technician - CLRT

# of Exams

If you need different types of exams, please submit separate orders for each.
Your credit card will be charged for the number of exams at the current fee for each, plus shipping when applicable. Proctor exam agreement terms are applicable.

Type Credit Card

Visa MasterCard Amer Express Discover

Card #

Exp Date

Name on Card:

3 or 4 Digit Security Code

I hereby authorize charges to my credit card for the above listed examinations and shipping

Please enter the text into the box & submit

This form does NOT automatically process your credit card. We do that manually in the office.

If you have any issues with this auto payment form you can always contact us and we'll send an email invoice that has a quickbooks payment link directly in the invoice.