Sigma Gamma Rho Sorority, Inc.
Sigma Gamma Rho Sorority, Inc. CREDIT CARD AUTHORIZATION FORM PLEASE ATTACH REMITTANCE FORM AND SUMMARY
Chapter Name: ___________________________________________________________ Name ___________________________________________________________________ Last First Middle Address _________________________________________________________________ City ___________________________
State ______
Zip ________________
Daytime Phone number: Email Address: ( print ) I authorize use of my credit card for the following: TORCH Fees ____________________________________________________________________ National Obligations (submit remittance form) _________________________________________ Orders (submit order form) _________________________________________________________ Other_________________________________________________________________ American Express
Discover
MasterCard
Visa
□ Diners Clubs
Card Number ________________________________________________________________
*V-code:
Exp. Date Total Amount of Charge(s)
___________________
Total Authorized (include $5 handling fee)
___________________
Signature _______________________________________________________________ * Verification Code. A 3 – 4 digit non embossed number found on card signature panel or near embossed account number on front. Sigma Gamma Rho Sorority, Inc. 1000 Southhill Drive, Suite 200 Cary, NC 27513
Phone: 919.678.9720 Fax: 919.678.9721
Updated 7/2014
Chapter Name: ___________________________________________________________ Name ___________________________________________________________________ Last First Middle Address _________________________________________________________________ City ___________________________
State ______
Zip ________________
Daytime Phone number: Email Address: ( print ) I authorize use of my credit card for the following: TORCH Fees ____________________________________________________________________ National Obligations (submit remittance form) _________________________________________ Orders (submit order form) _________________________________________________________ Other_________________________________________________________________ American Express
Discover
MasterCard
Visa
□ Diners Clubs
Card Number ________________________________________________________________
*V-code:
Exp. Date Total Amount of Charge(s)
___________________
Total Authorized (include $5 handling fee)
___________________
Signature _______________________________________________________________ * Verification Code. A 3 – 4 digit non embossed number found on card signature panel or near embossed account number on front. Sigma Gamma Rho Sorority, Inc. 1000 Southhill Drive, Suite 200 Cary, NC 27513
Phone: 919.678.9720 Fax: 919.678.9721
Updated 7/2014
