Credit Card Slip - Lifetime

Law Student Organization Credit Card Charge Form
Card Number

 Visa

 MC

 Discover

Auth. Code

Date

$ 30.00
Exp. Date
S treet Street Ci

Name EXACTLY as shown on card
ty City S tate State ZIP ZIP Telephone Number Telephone Number

Amount
Cashier Authorization

Cardholder Information

Cardholder Signature

Law Association for Women
Organization Information

O

rganization Name Organization Name

Pur

Lifetime Membership Dues

pose for Charge Purpose for Charge

The cardholder agrees to pay the sum set forth above to the bank or card issuer in accordance with the terms of the credit card for the purchase of goods or services.

Payment Taken By

Deposit to
Account #_____________