CREDIT CARD AUTHORIZATION FORM

Visa __ / MasterCard __ / American Express __ / Discover __

Card Number: 	_____________________________________

Expiration Date:	_____________________________________

Security Code: 	_____________________________________

Name on Card:	_____________________________________

Billing Address:	_____________________________________

			_____________________________________

			_____________________________________

Tel Number:	_____________________________________

I hereby authorize Northern Virginia ASQ Section 0511 to charge the above card for the amount of $______________________________

Cardholder signature:	__________________________________

After completion, please email or fax this form back to Northern Virginia ASQ Section 0511 as indicated below. If ordering a document, we will not release it until we have received this credit card authorization.

Receipt:

Date Processed:_______ Signature:________________ Position: _______________