Ditchmen • NUCA of Florida Ditchmen - November 2019 | Page 38

Proceeds to benefit Construction Angels
2019 Clay Shoot
Please print clearly – All information is required to process transaction
Type of Credit Card:
Visa _____
MasterCard _____
American Express_____
Card Number: ____________________________________________________
Expiration Date: __________
Verification Code: __________(3 or 4 digit)
Name on Card: ____________________________________________________
Company Name: ___________________________________________________
Billing address for credit card: ________________________________________
City: _________________________
State: __________
______________________________
Zip: __________
_____________________________
Print Name Authorized Signature
______________________________ _______________________________
Company Name Phone Number
Email address: ______________________________________________________
Amount authorized to charge: $_______________
Date authorized: ____________________
36
Rhonda Cason, Executive Director
NUCA of Southwest Florida
P. O. Box 62207, Fort Myers, FL 33906
DITCHMEN • NOVEMBER 2019
Phone [phone], Fax [phone]