Mrs. Paula R. Leder, ICP Financial
Officer |
c/o Dr. Matti K. Gershenfeld,
Secretary General |
The Colonade, Suite #1201 |
100 Old York Road |
Jenkintown, PA 19046 |
|
2. CREDIT CARD/FAX _________ Enclosed is my
Credit Card Authorization (see below) |
(You may FAX or EMAIL your Dues Form/Application only
if paying by Credit Card) |
ICP accepts only payments by
VISA or MASTERCARD |
|
ICP Credit Card Authorization Form (Please TYPE or
PRINT) |
Please Complete Both the DUES APPLICATION and the
CREDIT CARD AURTHORIZATION: |
|
I authorize _______ VISA _____ MASTERCARD
payment for $ ____________ (U.S. Dollars) |
For Membership / Dues, Newsletter, Fees and/or
Contributions to the International Council of Psychologists (ICP) |
|
Card Number
_________________________________________ |
Exp Date __________________ (MM /YYYY)
|
|
IMPORTANT! Full
Name & Exact Address where Credit Card Mails Your Bill.
INCLUDING Full Zip/Mail Code. |