CRWAD Credit Card Payment
- 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."