PERSONAL INFORMATION:

Your Name  (first and last)        Phone Number

Your Employer (company)               

Your Employee Number  

Your Email Address

BILLING INFORMATION:

Total Amount $       Today's Date (dd/mm/yyyy)  

Credit Card Type (Master Card, Visa, etc.)  

Credit Card Number    Expiration Date (mm/yy)  

VPN Number (3 digits on the back of the card)

Name on the Card     Billing Address Zip Code

DESCRIPTION OF PAYMENT:

(Below fill in a description for reason of payment)

(example: $35 past dues, $15 dues for October, and a $20 donation to the strike fund for a total of  $70.00)