LOCAL 56 B.A.C.  371 S. MAIN PLACE, CAROL STREAM, IL  60188 

PHONE:  630 653-5920     FAX:  630 653-5975   

LAST NAME ________________________FIRST _____________________M.I.____ IU#_____________

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I AUTHORIZE LOCAL 56 B.A.C. TO BILL THE CREDIT CARD LISTED BELOW AS INDICATED:

ONE TIME CHARGE: 

$____________Apply towards fees owed including Initiation Fee, Membership Dues and/or any Fines.

-OR-

AUTOMATIC BILLING:  Apply towards Dues beginning (Date) _____________:

$ ______ Quarterly/3 months Dues           

$_______Semi-Annually/6 months Dues

$_______Annually/12 months Dues

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CREDIT CARD INFORMATION

(Circle One) Visa/Mastercard #_______________________________________________

Exp.Date_______________Verification # on Back _________________

Name exactly as it appears on the Card________________________________________

Contact # (must be listed) ___________________________

Street___________________________City_________________State_____Zip________

Signature______________________________________________Date________________

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Office to complete:

Received by_________________ Date_____________Phone_____Fax_____Other____________