Replacement Sign Form Historical Society Of Michigan Page 4

FOR PAYMENT BY CREDIT CARD ONLY

To charge your application fee to a major credit card (Visa, MasterCard, Discover or American Express), please complete

the following form. Do NOT complete this page if paying the application fee by check or money order.

SIGN TYPE

PRICE PER SIGN

TOTAL

Centennial Replacement Sign

$91.50/ea x ______

$___________________

Sesquicentennial Replacement Sign

$46.10/ea x ______

$___________________

TOTAL AMOUNT TO BE CHARGED:

$___________________

Credit Card Type:

Visa

MasterCard

American Express

Discover

Credit Card Number: _______________________________________________________________________________

Expiration Date: ____________________________ CVV Code: _____________ Billing Zip Code: __________________

(3-DIGIT CODE ON BACK OF CARD)

I authorize the Historical Society of Michigan to charge my credit card for a replacement sign.

Signed: __________________________________________________________ Date: ___________________________

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