BACK to GPOS HOME

GOTO Becky's ONLINE Payment Form
Contact Becky by email or
586.871.8351
OR You can use the Mail-in Form Below
 

[FrontPage Save Results Component]

2009 Grand Prix of Swing
Mail-In Event Video DVD Order FoRm

AFTER COMPLETING THIS FORM,
HIT "PRINT" ON YOUR BROWSER BAR.

Your Information

Name:

Street Address:

City:
   State: Zip:
Phone:
Email: (required)
DVDs will be available within 4-6 weeks after event.
NUMBER OF DVDs...............  
  

............................................................Total Amount Enclosed $

Please make checks payable to "Becky Larson"
If paying by credit card, please complete the information below.  For security purposes, you must complete the credit card information by hand. 
Credit Card Payments - Processed through Pay-Pal(r)

Credit Card Type- Check One
 
 Visa    MasterCard    Amex    Discover
ADDRESS PROVIDED ABOVE MUST MATCH THE BILLING ADDRESS FOR THE CARD.
Name Exactly as it appears on the Card:
                                                   

Credit Card # - print Clearly

                                 

Expiration Date: MM/YY

/

3-digit Security code on back of card

I authorize the above credit card for TOTAL purchases as indicated above:

Signature:________________________________________________

PRINT THIS FORM FROM YOUR BROWSER and Mail to: 
Becky Larson...45369 Northport Drive, #3312...Macomb, MI 48044
For Security reasons, PLEASE CLOSE THIS BROWSER WINDOW AFTER PRINTING--your information will not be saved OR TRANSMITTED across the Internet.

If you have any questions, please contact Becky at WCSwingDance@yahoo.com