Fax Cover Sheet

To:   Jane Smith
American Academy of Religion
Fax:  1-404-727-7959
From:                                                                                                                         
 
 
 
 

Memo:

I authorize the credit card listed below to be charged by the American Academy of Religion.

  
 
Order ID:  
 		  
 
Credit Card Type:
 		 circle one:    MasterCard    Visa    American Express    Discover    
 
Credit Card Number:
 		  

Card ID Number (CID):
 		 4 digits on front of American Express; 3 digits on back of other cards
 
Expiration Date:
 		  
 
Cardholder's Signature:
 		  
 
Phone Number:
 		  
 
Amount:
 		  
US$