2010 CAPITOL BICHON BASH DONATION PREPAYMENT FORM

Since the Bash is only a few days away, you will need to pre-pay with VISA or MasterCard.
DOWNLOAD AND PRINT this form, fill out, and fax to Jill at 301-762-6422.
If no fax is available, payments may be phoned in to 301-762-6022 from 12 - 9 PM Eastern

Name on Bichon Bash
Online Registration
[Cardholder] Name
[Billing] Address
City, State, ZIP
Work ___ or
Cell ___ Phone
Home Phone
Email Address
Form of Payment
 VISA ____ MasterCard _____ Check _____
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
 
@ $10.00 ea
$

Age 5 - 11

  
@ $5.00 ea
 $
Under 5 yrs
 
No Charge
$

 

 

 

 

Additional Donation to Bichon Rescue
to help pay Veterinary Expenses (optional)
$
TOTAL DONATION
 $




See you at the Bash!