Name as it appears on Membership Agreement

Scanner Card Number

Payment Method Payment Method VISA MASTERCARD DISCOVER

Payment Amount $

Name as it appears on Credit Card

Credit Card Number

Expiration Date

Card Security Code (3 Digit Number From Back Of Card)

Street Address

City

State

Zip

Daytime Phone

Alternate Phone

Email Address

Comments

This Credit Card should be used for: This Credit Card should be used for: One time payment only. For this payment and all future payments. Secondary payment source if primary fails.