Credit Card Payment Form

Please print and completely fill out the following form to ensure timely processing. Credit card and address information is confidential; the completed form should be faxed to

FAX: +1.202.351.0511

or mailed to OSAIC at:

OSAIC
10490 NW 48th Street
Doral, FL 33178
USA

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Enter your credit card billing information (* = required) .  This must match your credit card statement address.
(We will use this address for mailing our acknowledgement letter unless you enter a different address in the Mailing Address section):

Title	Mr. Ms. Dr. Mrs. Miss Prof. Rev. Sgt. Capt. Maj. Col. Other
*Your Name
Organization
*Street Address
Address (cont.)
*City
*State/Province
Zip/Postal Code
Country
Home Phone
Work Phone
FAX
*E-mail

 

 

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Credit Card Information

*Credit Card Type	MasterCard VISA American Express Discover
*Name on the card
*Card Number
*Expiration Date
*Donation Amount ($)
Card Validation Number	(last 3-digit number on signature strip on back of card; 4-digit number in front of American Express card)

By signing this form, I authorize OSAIC to charge my credit card for payment.

Your signature:______________________________ Data:____________

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Mailing Address (if different than billing address):

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Thank you for your donation!

Please visit us on the web at http://www.osaic.org