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American Warmblood Society
2 Buffalo Run Road Center Ridge, AR 72027 501-893-2777 fax: 501-893-2779 email: aws@americanwarmblood.org |
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: ____________________________
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:_________________________________________
1-22-08