Credit Card Payment Fax Form

Credit Card Payment Fax Form Fax To: 608-531-6385 Please Check One: _____ Visa _____ American Express _____ Discover Card _____ MasterCard ___________________________________________________ Credit Card Number: ___________________________________________________ Name (as it appears on card): ___________________________________________________ Signature of Cardholder: _____________________________________________ Expiration Date: _____________________________________________ Amount To Charge: _____________________________________________ Date: ___________________________________________________________________________________________________________ Billing Address: City: State: Zip: