בס"ד

FRIENDS OF ELON MOREH

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NAME:        ___________________________________________________

 

ADDRESS: ___________________________________________________

                   

____________________________________ZIP:___________

 

COUNTRY:          ___________________________________________________

 

TELEPHONE:       |__|__|__|-|__|__|__|__|__|__|__|

 

CELL-PHONE:     |__|__|__|-|__|__|__|__|__|__|__|

 

E-MAIL:               ______________________________________________

 

_Enclosed please find a check in the amount of _______________.   

 

_Please debit my credit account.

 

  _VISA   _MASTER CARD    _DISCOVERY

  _AMERICAN EXPRESS       _DINERS CLUB

 

ACCOUNT NUMBER:  

|__|__|__|__|-|__|__|__|__|-|__|__|__|__|-|__|__|__|__|   verification no. |__|__|__|

 

EXPIRATION DATE:    |_____| - |_____|

 

CARDHOLDER’S NAME: ______________________________________

 

PAYMENT AMOUNT: __________    NO. OF PAYMENTS _____

 

TOTAL  ____________

 

PROJECT:       ______________________________________________

 

SIGNATURE:       ______________________________________________