Credit Card Secure Form

MIAMI BEACH ROWING CLUB

GENERAL PROGRAM PAYMENTS

Credit Card Authorization Form

VISA or MASTERCARD ONLY

Contact Information

First Name *

Last Name *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

NOTES - Please specify what program/fees are authorized in detail

Please Indicate AMOUNT Authorized for Payment: *

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CCV *

Credit Card Charge Acknowledgment *

I understand my credit card will be charged for the amount stated above within the next 48 hrs.

Cardholders Signature *

Date *

Signature Acknowledgment *

By typing my name above I agree this is a valid form of my signature