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Kenosha Symphony Orchestra Scheduled Credit/Debit Card Payment Form Please print this form, complete, and mail to: Kenosha Symphony Association 6501 Third Avenue Kenosha, Wisconsin 53143 |
Name:___________________________________________________________
Telephone:_______________________________________________________
Email Address:____________________________________________________
I authorize a charge against my credit/debit card on the 1st of each month,
in the following amount: $______________
Starting Date:_____________________ (MM/DD/YY)
Card: (choose one) ___MasterCard ___Visa
Account No.______________________________________________________
Expiration Date:___________________________________________________
Billing Address:___________________________________________________
City/State/Zip:____________________________________________________
Signature________________________________________________________
Today's Date:_____________________________________________________
Note: Scheduled charges will remain in effect until revoked in writing to the Kenosha Symphony Orchestra Office.
Your contribution is tax deductible to the extent allowed by law. Please consult with your tax advisor for further infomation.