Credit Card Form Agreement

The Valley Relics Museum 501(c) 3
7900 Balboa Blvd C3 & C4
Lake Balboa, CA 91406
www.valleyrelicsmuseum.org

Bill to *

Business Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Ship to *

Business Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please check this box if the ship to address is a Residential address:

Name as printed on card *

Billing address for credit card *

Address Line 1

Address Line 2

City

State

Zip Code

Credit Card Number *

Expiration *

CV Code *

(3 or 4 digits on back/front of card after the number)

Type of Credit card *

Check one or more options

Invoice to be paid

I assume personal and individual responsibility and liability, and guarantee payment of all charges due and payable to Valley Relics.

All information listed will be kept strictly confidential.

Please send us a photocopy of the card after form is submitted. Email Mercedes@valleyrelicsmuseum.org

Signature of Card Holder *

Clear Signature

Print Name *

Title *

Date *