If any family members wish to charge their deposit or balance of payment on a credit card, we accept VISA, MasterCard,
Discover or American Express. Below list the person wishing to charge, their credit card number, expiration date and
amount to be charged along with their signature. Please send this information along with your registration.
(One form per family group.)
CREDIT CARD TYPE:
m
VISA
m
MC
m
AMEX
m
DISC
Exp. Date: ___/___/___ Total Amount Charged: $________________
Account Number:
nnnn nnnn nnnn nnnn
m
Deposit
or
m
Balance of Payment*
Name (Print)
Signature
( )
( )
Billing Address*
Daytime Telephone Number
Cell Phone Number
City, State Zip
Email Address
If this credit card payment is not for your entire group, please list person(s) and amounts to be paid with
this credit card.
List person(s) and amounts to be paid with this credit card.
Person(s)
Amount
1. ________________________________________ ________________________________
2. ________________________________________ ________________________________
3. ________________________________________ ________________________________
4. ________________________________________ ________________________________
5. ________________________________________ ________________________________
6. ________________________________________ ________________________________
7. ________________________________________ ________________________________
8. ________________________________________ ________________________________
9. ________________________________________ ________________________________
10. ________________________________________ ________________________________
*Please complete this form for each charge (i.e. charge your deposit in January and then complete
another charge form in February to charge your balance).
CREDIT CARD PAYMENTS
2014 UCA INTERNATIONAL ALL STAR CHAMPIONSHIP
Gym Name _____________________________________________________________________________
Team Name _________________________________________ City__________________ State______ Country_______________
BALANCE OF PAYMENT IS DUE FEBRUARY 12, 2014
* In order for credit cards to be processed, we MUST have the billing address for the credit card being charged.
This address MUST include the zip code for the billing address.
THIS FORM MAY BE DUPLICATED.
14
Please tear out along the perforations. You may make copies of this form.
PARTICIPANT CREDIT CARD PAYMENT
