Credit Card Form

I want to pay my bill by credit card:

PLEASE PRINT CLEARLY

Name: ______________________________________________________

Office: ______________________________________________________

Credit Card Type: VISA

MasterCard

We do not accept AMEX

Credit Card Number: ___________________________________________

Credit Card Billing Address: _____________________________________

City, State, Zip: _____________________________________

Name on Credit Card: __________________________________________

Expiration Date: ______________________________________________

Dues

Education

Invoice

Event

I am paying for:

I authorize the TSBOR and/or the TSMLS to charge the amount below to my

credit card: $______________

Signature: ______________________________________________________

Please send a receipt to the address listed above.

FAX TO 530-583-1015

*Please note, all credit card information will be destroyed after processing

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Parent category: Financial