Billing Information
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Credit Card
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Expiration Date:		1 2 3 4 5 6 7 8 9 10 11 12 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
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I authorize Well-Being Group, Inc. to charge the above account for payment of their products and/or services. If Well-Being Group, Inc. is unable to process my payment I will be responsible for an alternate payment arrangement and any resulting processing fees. By submitting this form, I acknowledge that I have read and agree to all of the above information and warrant all information given is true.
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