HWA Dues Payment Form

Your name: ____________________________________________________________

Cardholder's name: ____________________________________________________

Billing address: ______________________________________________________

___________________________________________________ Zip _______________

Your amount due: __________________

____Check or money order (If you are using this method, there is no need to fill out the rest of the form.)

____VISA ____MasterCard ____American Express

Card number __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Expiration date (mm/yy) ___ ___ / ___ ___

CVV2 number ___ ___ ___

(The CVV2 number is the last three or four digits of the number that appears in ink on the back of your card. If you don't have this number, leave it blank.)

Cardholder's signature ________________________________________________________

If paying in $US or by credit card, mail the form with check/money order or card info to: Lisa Morton/ HWA Treasurer/ 5022 Riverton St. #9/ N. Hollywood, CA 91601/ USA

If paying in pounds sterling by cheque or money order, mail the form and payment to: Jo Fletcher/ 24 Pearl Road/ Walthamstow, London E17 4QZ/ UNITED KINGDOM