METHOD OF PAYMENT

Applicant Information

Event:      

Membership: □             Parades □             Den Party □            Balcony Party □     Epiphany: □  

Miscellaneous: ____________________________________________________________________(Description)  

Name On Card:

Phone:  

 Work Email Address:  

 Personal Email Address:

Current address:

City:

State:

ZIP Code:

Amount of Purchase:

We Accept the following Credit cards (please check one)

Visa   □          Debit: □   or     Credit: □  

MasterCard  □      Debit: □   or     Credit: □  

Credit Card Number

Expiration Date:

V  Code (on back of card) 

I agree to pay the above total

Signature of Buyer:

Date: