Florida Education Foundation Credit Card Authorization Please complete this form then fax it to Marilyn Parcels at 850-245-0849. Event Information Event NCLB Technical Assistance Meeting Amount ? $150.00 Attendee Payment/Authorization Information Accepted Payment Method: ? Visa ? MasterCard ? American Express ? Discover Card Number (enter number without spaces) Expiration Date (mmyy) Amount (i.e.,10.00) Signature Customer Billing Information First Name Last Name Company Address City State/Province Zip Code Country Phone Fax Email For Office Use Only ? Charge a Credit Card ? Refund a Credit Card By Customer ID Date Transaction ID
Allowed
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