PAYMENT FORM FOR NCLC APPLICATIONS, RENEWALS,
CREDENTIALS VERIFICATION, ETC..
If you are a Proctor ordering exams, please go to the "Contact" page and place your order there.

If you download the form for applications or renewals and send it in, plus complete this form for your payment information, then it will be processed accordingly. Please note that payments made here will go through as a charge from our parent non-profit organization - Professional Medical Education Assn. Please type in the "remarks" box what the payment is for.

Name

Address
(associated with credit card)

Contact Phone #

Email address (REQUIRED)

Confirm Email

REMARKS - what the payment is for, and who it is for, plus any other remarks.

Please list address exactly as it would printed on a mailing envelope, mailed from the U.S.

Please enter the txt into the box, then submit

PAYMENT
METHOD

Credit Card Type:

CHOOSE HERE VISA MASTERCARD AMERICAN EXPRESS DISCOVER

Amount Authorized:
If this differs from the required charge, we'll contact you.

Credit Card Number

Cardholder Name

Expiration Date

mm/yy

3 or 4 Digit Security Code on back:

I hereby authorize charges to my card for the item(s) listed.

By placing this order and clicking the SUBMIT button below, you acknowledge that you have read the NCLC CERTIFICATION HANDBOOK and agree with its terms.

After you SUBMIT your order we'll followup within 24 hours after we've processed your renewal/payment.
All registrations are manually processed by staff.