| Credit Card Authorization
Agreement To Charge Credit Card
(please print out)
| I hereby give my permission for the Independent Broker's Association, 40 Lake Bellevue Dr., #100, Bellevue, WA 98005, to charge my Credit Card for the following event only: |
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| Name of Event |
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| (Visa, MasterCharge)(Name of Card) |
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16 Digit Number on Front of Card |
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| Mon/Yr Expire Date |
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3 0r 4 digit code on back of card |
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| Full Street, City, & State (Must be the same as billing address of card) |
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| Signature |
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Date |
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| Mail or Fax to: |
| Independent Broker's Association |
| 40 Lake Bellevue Dr., #100 |
| Bellevue, WA 98005 |
| Fax: (425) 455-4286 |
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(c)2007:IBA
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