CREDIT CARD TRANSACTION

 

 

Date Submitted: _________________              Horse Reg # : _______________  (if known)

 

Transmission Date: _________________ (Office use only)

 

Credit Card Type:  Master Card  ____     Visa ____   (check one)

 

Name (as appears on card): _________________________________________________

 

Credit Card #: ____________________________________________ 

 

Expiration Date:   ____________________________(mm/yyyy)

 

Amount charged:  $____________    (minimum $25)

 

Address: _____________________________________________________________

 

City: ____________________________________ State: _____   Zip Code: ____________

 

Phone #: (          ) ____________________    Fax #: (          ) ____________________

 

Email: ________________________________________________________________

 

Charge Description:  (break down by line item)

 

. Owner Name_______________________________________________________________

 

. Horse Name(s)_____________________________________________________________

 

.________________________________________________________________________________________________

 

.________________________________________________________________________________________________

 

.________________________________________________________________________________________________

 

._________________________________________________________________________________________

 

.__________________________________________________________________________

 

Signature:_________________________________________

                                                                                                                                                7-07-09