Proceeds to benefit Construction Angels
December 10 , 2021 Clay Shoot - Payment Form
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 ______________________________ Company Name
_____________________________ Authorized Signature _______________________________ Phone Number
Email address : ______________________________________________________ Amount authorized to charge : $_______________ Date authorized : ____________________
Rhonda Cason , Executive Director NUCA of Southwest Florida P . O . Box 62207 , Fort Myers , FL 33906 Phone 239 / 939-1952 , Fax 239 / 790-1369
“ Building Southwest Florida From the Ground Down ”
NOVEMBER 2021 • DITCHMEN 55