Pediatric Cancer Treatment Foundation

   Credit Card authorization Form
____________________________________________________________

Please fill out and return via e-mail to rtrigueros.pctf@att.net
NAME ___________________________________________________________
ADDRESS _________________________________________________________

CITY ____________________ STATE _______  ZIP CODE ____________

PHONE _______________________

E-MAIL _____________________________

 I (name) _________________________ hereby authorize Pediatric Cancer Treatment Foundation to charge the following…

(circle one)
AMEX                   MASTERCARD                        VISA

Credit Card Number: _______________________________________________

Expiration Date: ___________________ Security Code:______________

Credit Card Billing Address: ____________________________________
City:_____________________ State: _________ Zip Code:___________

 Signature: ____________________________  Date: _______________

Print Name: _____________________________________

Let’s put

an end to Cancer

world-wide!

Pediatric Cancer Treatment Foundation