CREDIT CARD PAYMENT INFORMATION

Please fax this information to Dr. Robert P. Ellis
Fax : 970-491-1815

CRWAD dues and meeting registration fees may be paid by credit card.  If you are paying meeting registration fees a completed pre-registration form must accompany the credit card information.
Accepted cards are: MasterCard, VISA, American Express, and Discover credit cards.

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If you would like to make payment by credit card please complete and fax the following information.

Credit Card Number ________________________________________
Expiration Date __________
Verification No. (This is the 3 digit number - it may follow a 4 digit number- which appears on the signature strip on the back of the card) ______
Name on the card _______________________________________
Street Address _________________________________________
Zip/Country Code _______________
Type of credit card (Visa, MasterCard, American Express, or Discover) _______________
What are you paying (Dues and/or registration) _________________________________________
Amount you are paying _______________

Please include a Confidentiality Notice on the Cover Sheet when you fax your personal information. You may use the following statement:

"Confidentiality Notice – The content of this fax contains confidential information, intended only for the person(s) named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or any other use of this information is strictly prohibited. Please destroy the information immediately and all copies thereof. If you have received this fax in error, please notify us by telephone at 970-491-5740."