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Revised 3/2004 Charge Card Authorization Slip Name on Card Chapter Card Number Expiration Date Today s Date Description Amount Circle your credit card type Required for security verification purposes. Please provide your credit card billing address and zip code. Purchaser signature Address and Zip Visa Discover American Express Subtotal Tax Total Mastercard 3 last numbers on the back of the credit card excluding AMEX CDI Phone Number Your statement will read BNI Enterprises Inc. Upland CA Upon your acceptance to BNI participation fees are non-refundable. My signature above authorizes BNI to process my credit card for the amount listed on the slip. Facsimile signature same as original. Copyright 1996 2006 BNI All Rights Reserved FORM No. 0129. Revised 3/2004 Charge Card Authorization Slip Name on Card Chapter Card Number Expiration Date Today s Date Description Amount Circle your credit card type Required for security verification purposes. Please provide your credit card billing address and zip code. Purchaser signature Address and Zip Visa Discover American Express Subtotal Tax Total Mastercard 3 last numbers on the back of the credit card excluding AMEX CDI Phone Number Your statement will read BNI Enterprises Inc* Upland CA Upon your acceptance to BNI participation fees are non-refundable. My signature above authorizes BNI to process my credit card for the amount listed on the slip* Facsimile signature same as original* Copyright 1996 2006 BNI All Rights Reserved FORM No* 0129. Revised 3/2004 Charge Card Authorization Slip Name on Card Chapter Card Number Expiration Date Today s Date Description Amount Circle your credit card type Required for security verification purposes. Please provide your credit card billing address and zip code. Purchaser signature Address and Zip Visa Discover American Express Subtotal Tax Total Mastercard 3 last numbers on the back of the credit card excluding AMEX CDI Phone Number Your statement will read BNI Enterprises Inc* Upland CA Upon your acceptance to BNI participation fees are non-refundable. Please provide your credit card billing address and zip code. Purchaser signature Address and Zip Visa Discover American Express Subtotal Tax Total Mastercard 3 last numbers on the back of the credit card excluding AMEX CDI Phone Number Your statement will read BNI Enterprises Inc* Upland CA Upon your acceptance to BNI participation fees are non-refundable. My signature above authorizes BNI to process my credit card for the amount listed on the slip* Facsimile signature same as original* Copyright 1996 2006 BNI All Rights Reserved FORM No* 0129.