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 PLEASE
NOTE: Visa and MasterCard International will add a 2-3% currency
conversion fee to your charge amount. Your credit card issuer may add on
an additional percentage. We process your charge at an exchange rate of
2:1. Therefore, please contact your issuer about any additional amounts
over that authorized below.
PLACENCIA HUMANE SOCIETY
Placencia, Belize
LETTER OF AUTHORIZATION TO CHARGE CREDIT CARD
I authorize the Placencia Humane Society to charge
to the following described credit card the amount of $______________
U.S. Dollars for the following (please check applicable
category):
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Membership as a __Benefactor (US$500
Lifetime Membership), ___Patron (US$50 to US$499/year) ____
Family (US$15/year), ____ Individual (US$10/year), ___Student
(US$5/year) Coffee Mug:
US$10.00 plus US$7 shipping/handling per mug
Womens Crop Tank Top US$17.50 + US $6
S&H per shirt (Size S, M, L, XL):____________________ |
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T-shirt: US$15.00 + US$6 S&H per shirt.( Size S, M, L,
XL):________________________ |
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Other Donation:
to be used for
_________________________________________________ |
(If you are joining as a Patron or Benefactor, please be sure to indicate
your T-shirt size above.)
Card
Holder's Name On
Card:________________________________________________________
Credit Card Type: _____ MasterCard _____ Visa
Credit Card Number:
__________________________________________Exp. Date:___________
Cardholder's Contact Information, including billing
address:
Street
Address:____________________________________________________________________
City:_____________________________________________________________________________
State/Province/District:______________________________________________________________
Country: _________________________________________Zip
Code:________________________
Billing Address Phone: _________________________Alternate
Phone:_______________________
Billing Address Fax:______________________________Alternate
Fax:_______________________
Email
Address:___________________________@_______________________________________
Signature:________________________________________________________________________
Printed Name:___________________________________________Date:______________________
Placencia
Humane Society
General Delivery
Point Placencia, Stann Creek District, Belize, Central America
U.S
E-FAX Number 1-773-357-8658
Email: info@placencia-pets.org
Website: www.placencia-pets.org
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