Pediatric Cancer Treatment Foundation
Let’s put
an end to Cancer
world-wide!
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: _____________________________________