| Credit Card Form |
Payable to RASIT Account
Please charge the following account for the amount of
US$
Mastercard Visa
Card Number:
Expiry Date: Security Code:
Cardholder’s Name:
Cardholder’s Address:
Tel: (wk)
(hm)
Cardholder's signature:
Your signature on this form authorizes RASIT to charge your account for the actual amount mentioned.
Receipt will be sent to your mailing address.
Please Print and send this form via Fax or mail.
Fax No.: USA +1 -201 - 340 4264
Mail: PO Box 1557 Rutherford NJ 07070 USA
Please charge the following account for the amount of
US$
Mastercard Visa
Card Number:
Expiry Date: Security Code:
Cardholder’s Name:
Cardholder’s Address:
Tel: (wk)
(hm)
Cardholder's signature:
Your signature on this form authorizes RASIT to charge your account for the actual amount mentioned.
Receipt will be sent to your mailing address.
Please Print and send this form via Fax or mail.
Fax No.: USA +1 -201 - 340 4264
Mail: PO Box 1557 Rutherford NJ 07070 USA
| RASIT is a 501(c)3 non-profit non-governmental organization associated with DPI - United Nations |
| jeans 4 genes International Program |
