2008 CAPITOL BICHON BASH DONATION PREPAYMENT FORM

If paying by VISA or MasterCard:
Print this form, fill out, and fax to Jill at 301-762-6422.
If no fax is available, charge payments may be phoned in to 301-762-6022 from 12 - 9 PM Eastern.

SORRY .... There is no longer sufficient time for you to submit your prepayment by mail.
Please prepay using a credit card and follow directions listed above.

Name on Bash Online
Registration
[Cardholder] Name
[Billing] Address
City, State, ZIP
Work ___ or
Cell ___ Phone
Home Phone
Email Address
Form of Payment
 VISA ____ MasterCard _____ Check/Money Order _____
Credit Card #
Expiration Date
 (mm/yyyy)
CVV2/CVC2/CID
3-digit # on back of card

Registration Donation

Number of Persons Registered That Are:

Quantity

 Donation Per Person Total
Age 12 or older
 
@ $8.00 ea
$

Age 5 - 11

  
@ $5.00 ea
 $
Under 5 yrs
 
0
 $

 

 

 

 

Additional Donation to Maryland Bichon Frise
Rescue, Inc.for Veterinary Expenses (optional)
$
TOTAL DONATION
 $




See you at the Bash!