NTA
CREDIT CARD PAYMENT FORM

Attn: Charmaine J. Wright
FAX 
202 737-7308

Date ________________

Card: Master Card: ___   VISA:___
 
Acct. No: ______________________________________ 
 
Expiration Date Mo:______   Year: _______

Name On Card: _______________________________________________________

Name of the member (if different from above) _________________________________

Amount: ___________________
 
Signature                                                                                           
 
 
Confirmation on request.

 

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