Oklahoma State Medical Association Credit Card Transaction Form
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1Oklahoma State Medical Association
313 NE 50th, Oklahoma City, Oklahoma 73105
405-601-9571 405-601-9575 (fax)
Credit Card Transaction Form
Invoice
Description
Workers Compensation AMA Guides Sixth Training
Payment/Authorization Information (complete the following information
)
Visa, Mastercard, American Express, Discover
Card Number
Expiration Date
Amount
Card Code
(last 3 digits on back of card)
Customer Credit Card Billing Information
First Name
Last Name
Company (if using a company card)
Address (credit card billing address)
City
State/Zip
Phone
Signature_________________________________________________________________
Date_______________________________
OSMA Staff______________________________________________________________
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Parent category: Financial