Complete form, PRINT, sign, date and return to the address or fax number above.

Please provide the following information:

Name

Street Address

City/State/Zip

Contact Number

FAX Number

Please provide your Bank Account Information:

Bank Name and Branch

City/State/Zip

Account Number

Bank Transit/ABA Number

Please provide your Credit Card information:

Choose One MasterCard Visa

Card Number

Expiration Date (mm/yy)

Name as it appears on Card

3 Digit Security Code (Last 3 numbers in signature area on back of card)

Billing Address

City/State/Zip

Choose one of the following options:

$100        $200        $500      $ (Enter Amount)

Complete form, PRINT, sign, date and return to the address or fax number above.

Please read, sign and date:

As a convenience to me, I hereby request and authorize MSCA/LAF to pay or charge my checking account or credit card via electronic debits, checks or drafts, drawn on my account indicated above by and payable to the order of MSCA/LAF, provided there is sufficient collected funds in aid account to pay upon presentation.  I agree that MSCA/LAF rights in respect to each such draw shall be the same as if it were a check drawn on you and personally signed by me.  Furthermore, if this option is selected, I request and authorize MSCA/LAF to charge my credit card account, providing there is sufficient availability on my credit card account to pay upon presentation.  This authorization is to remain in full force, on a monthly basis, until the MSCA/LAF has received a written notification from me of its termination in such a manner as to afford the MSCA/LAF, the BANK, and/or the CREDIT COMPANY reasonable opportunity to act on it.

 

Account Holder Signature

Date

Please PRINT completed form, sign, date and return to the address or fax number above.