One Time Credit Card Payment Authorization Form



National Academy of Neuropsychology

7555 East Hampden Avenue, Suite 525

Denver, CO 80231

Phone: 303-691-3694 | Fax: 303-691-5983

2nd Annual Tony Wong Diversity Award Dinner

Make your reservation now, space is limited.

Deadline: Friday, November 7, 5:00pm Eastern time

Dinner will cost $45, charged at the event. Please use this form to make your donation, which will serve as your ticket for the event.

Name: ______________________________ Email address: _______________________

As this is a fund raising event for the Tony Wong Diversity Award, we ask that you make a donation in any amount as well. The annual budget for the Tony Wong Diversity Award is $1200. Your donation goes directly to the award to support diversity. Please complete and fax to (303) 691-5983. For questions, please contact DiversityCommittee@.

Please complete the information below:

I authorize the National Academy of Neuropsychology to charge my credit card for this amount:

________$35

________$50

________$75

________other

Billing Address ____________________________ Phone# ________________________

City, State, Zip ____________________________ Email ________________________

| Account Type: Visa MasterCard |

| |

|Cardholder Name _________________________________________________ |

|Account Number _____________________________________________ |

|Expiration Date ____________ |

|CVV2 (3 digit number on back of Visa/MC) ______ |

SIGNATURE DATE

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

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