Credit Card Form

Credit Card Form
(Right Click to PRINT this form. Have it
completed and Mail or Fax to the address
below.)

Name: _____________________________

Company: __________________________

Address: ___________________________

City: ___________ State: ____ Zip: _____

Phone: ____________________________

Fax: ______________________________

Credit Card:
___VISA ___MasterCard ___American Express

3 or 4-Digit Reference Number: ________

Card Number: _______________________

Expiration Date: ____________

___________________________________________
Card Holder’s Name (Please print)

____________________________________________
Signature of Card Holder

Mail or Fax to:
WIFLE
2004 Conference
PO Box 1480
Edgewater, MD 21037-7480
E-Mail: cbaumgardner@time andconvenience.com
Phone: 866-399-4353 Or 866-39WIFLE
Fax: (410) 798-9556
WIFLE Privacy Policy