DUI Program Payment

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Instructions

You may submit a credit card payment for the DUI Program in which you are or were enrolled, using this form.

You will be automatically sent an email confirming this submission, to the email address that is included in this form, once you have selected the “Submit” button.

We will process this payment as soon as possible, typically within one business day.

Section 1: Client Information

Full Name: *

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Section 2: Program Information

Identify which Sacramento County Breining Institute DUI Program location you are or were attending: *

NORTH COUNTY: 8894 Greenback Lane, Orangevale

FOLSOM: 2360 E. Bidwell Street, Suite 107, Folsom

MID-COUNTY: 2775 Cottage Way, Suite 25, Sacramento

SOUTH COUNTY: 3159 Dwight Road, Suite 100, Elk Grove

Identify which of the following programs you are or were attending:

Wet Reckless program

3 month program

6 month program

9 month program

Other (or I am not sure which program)

Section 3: Payment Information

Please itemize and explain your payment here:

Include the total payment amount that you want to be charged to your credit card.

Section 4: Credit Card Information

You give permission to and authorize Breining Institute to charge the total amount of the items identified in Section 3, to the following credit card:

Credit Card: *

VISA

MasterCard

Discover

Credit Card Number: *

Full Name on Credit Card: *

Credit Card Expiration Date *

Captcha *

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