CREDIT CARD PAYMENT AUTHORIZATION

Member Information

First name:__________________________       M:_____           Last name:_________________________________________

Mailing address on credit card:___________________________________________________________________________

                                                            _______________________________________________Zip Code______________________

CARDHOLDER INFORMATION

Name on the credit card:________________________________________________________________________________

Visa                                               Mastercard

Credit card number:________________________________________________________

Expiration date:  month________   year_________

Card security code:______________   (this is the last 3 numbers on the back of the card)

I authorize the International Brotherhood of Electrical Workers Local Union 1253 to charge my quarterly membership dues the third week of each quarter which will be 4 times per year in the months of March, June, September and December.

Signature:___________________________________________________________________            Date:________________________________