PAYMENT TYPE (Check One) VisaMasterCardAmexDiscover Card
NAME SHOWN ON CARD (Please Print)
CREDIT CARD NUMBER
CARD SECURITY CODE
AUTHORIZED SIGNATURE ON CARD
CONTACT NAME(S) (Please Print)
CONTACT PHONE NUMBER
* Fill out and print or print the blank form and complete the entire form legibly with a dark pen. Card holder must sign on the line indicated. * IMPORTANT: A fee of 3.5% will be charge additionally to the amount due, this fee covers merchant charges.