CRWAD Credit Card Payment

Options available:

  1. PayPal
    Member dues
    Meeting Registration
    Purchase Proceedings

  1. Or, Fax
    Please fax the below information to Dr. Robert P. Ellis, Fax (confidential): 970-204-6684

Accepted cards are: MasterCard, VISA, American Express, and Discover credit cards.

Credit Card Number __________________________________________________ Expiration Date _____________________

Verification No. __________(3 digit number which may follow a 4 digit number and appears on the signature strip on the back)

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."