Name: ________________________________ |
Telephone: (_____) ______-_______ |
Type of Card (circle one): Visa Mastercard |
Card Number: _________________________ |
Expiration Date: _____/_____ |
Donation Amount:$ ____________________ |
Signature: _________________________ |
Mail completed and signed form to the address below or fax it to (206) 935-3061
Seattle Chapter of AMIGOS de las Américas
Treasurer
P.O. Box 30129
Seattle, Washington 98113 |
