Modrall Clients\81759\112\W1043483.DOC



-142875-1651000Credit Card Authorization Form This request is a one-time charge. By completing this form, you are authorizing a one-time payment from the credit card number provided below. Please check all areas that apply. Member Name: FORMTEXT ????? FORMCHECKBOX Commercial Association of REALTORS (CARNM) $ FORMTEXT ????? FORMCHECKBOX Commercial Association of REALTORS (CARNM) Building Issues and Advocacy Fund $ FORMTEXT ????? FORMCHECKBOX Commercial Information Exchange (CIE) $ FORMTEXT ????? FORMCHECKBOX One-Time Office Set-Up Fee $ FORMTEXT ????? FORMCHECKBOX One-Time New Member Fee or Membership Transfer Fee $ FORMTEXT ????? FORMCHECKBOX RPAC Donation $ FORMTEXT ????? FORMCHECKBOX RECPAC Donation $ FORMTEXT ????? FORMCHECKBOX Education Class $ FORMTEXT ????? FORMCHECKBOX CARNM CIE Administrative Access Processing Fee $ FORMTEXT ????? FORMCHECKBOX Annual Meeting Guest Fee $ FORMTEXT ????? FORMCHECKBOX Golf Raffle Tickets $ FORMTEXT ????? FORMCHECKBOX OtherDescribe: $ FORMTEXT ?????TOTAL TO CHARGE $ FORMTEXT ?????Credit Card Information FORMCHECKBOX Visa FORMCHECKBOX MasterCard FORMCHECKBOX Discover FORMCHECKBOX American Express Credit Card Number: FORMTEXT ?????Expiration Date: FORMTEXT ?????V Code (3 digit code on back of card): FORMTEXT ?????Credit Card Billing Information:Card Name: FORMTEXT ?????Billing Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????As the credit card holder, I hereby authorize the Commercial Association of realtors New Mexico to charge my debit/credit card.Cardholder’s Name: FORMTEXT ?????Cardholder’s Signature: FORMTEXT ?????Date Requested: FORMTEXT ????? ................
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