CREDIT CARD INFORMATION

Today’s Date:  _______ /_______ / _______

I, ______________________________________________, authorize Greater Phoenix NARI, to charge on my credit card the following:

Amount to be charged:  $_____________________________________

Reason for charge:  _________________________________________________________________

Circle Type:      VISA        MASTER CARD        AMERICAN EXPRESS          DISCOVER CARD

Credit Card #:   ___  ___  ___  ___    ___  ___  ___  ___    ___  ___  ___  ___    ___  ___  ___  ___

Expiration Date:  _______ /_______           Verification Number:   ___  ___  ___ 

Company Name: ____________________________________________________________________

Name As It Appears on Credit Card:  ____________________________________________________

Billing Street Address: ______________________________________________State: ____________