PALM SPRINGS WINTER CLASSIC 2012

ATTN: Vicki Oltean

401 S. Pavilion Way w Palm Springs, CA 92262

Telephone: (760) 323-8277 w FAX: (760) 323-8279

WINTER CLASSIC '12

CREDIT CARD AUTHORIZATION FORM  (due January 20, 2012)

Please print, sign and mail this Credit Card Authorization form to: Winter Classic, ATTN: Vicki Oltean, 401 S. Pavilion Way, Palm Springs, CA 92262. 

This payment is for Team: _________________________________________

Credit Card holder's Phone Number:_________________________________

Credit Card Type:   oVISA    oMasterCard    oAmerican Express

Credit Card No.:  oooooooooooooooo

Expiration Date (Mo./Yr.):   oo / oo

Verification Code (on Signature panel of your credit card):   ooo

Signature:__________________________________________

                                        Required with Credit Card Order