Athlete Name: __________________________________________
Mailing Address: ________________________________________
Home Phone: ________________________________Cell Phone: _________________________________
Email Address: ___________________________________________
|Non-Refundable Deposit||$200 (add $10 for credit card fee)|
Deadline is November 23, 2017, 10 AM
Amount $ Check #: _______________________ (We also accept Visa, MasterCard, and American Express. See below.)
Mail to: Sherri Hale, Northern Division USSA, P.O. Box 217, Whitefish, MT 59937
Name on Card: _________________________________________
Billing Address: _________________________________________
Card Number :____________________________________________
Expiration Date: _____________ Security Code (3digits): __________
With my signature I agree to pay for the above charged amount of _______ using my credit card that I have provided to Northern Division above. This includes the 5% surcharge to cover bank processing expenses. I understand that this is an estimated trip cost and adjustments will be made after all receipts are in. Credits will be mailed out at the end of the season as requested.
Signature: __________________________ Date: ________________
Notify Sherri that you want to be emailed a direct payment invoice. She will then mail you a link to use a safe, secure, encrypted transaction to send your bank account information via Intuit.