2011 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

PLEASE NOTE: This form is not interactive and cannot be completed or submitted online.

Name on Bichon Bash Online Registration
[Cardholder] Name
[Billing] Address
City, State, ZIP
Cell Phone
Home Phone
Email Address
Form of Payment	VISA ____ MasterCard _____
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 Rescue to Help Pay Vet Expenses (optional)	$
		TOTAL DONATION	$