LOCAL 56/20 BAC

371 S. MAIN PLACE, CAROL STEAM, IL 60188

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

Last Name__________________________First ______________ M.I._____

IU #___________

I authorize Local 56 B.A.C. to bill the card listed below as indicated:

Apply this amount towards my credit card: $___________________

Visa/Mastercard/Discover_________________________________

Expires ____ / ____               Verification # on back (last 3 numbers only)  ___________

Billing address of credit card:

Address_____________________________ City _______________ State ____Zip _________

Signature ____________________________________________ Date __________________

_____________ APPROVAL GIVEN TO KEEP FOR FUTURE REFERENCE

Office to complete:

Received by ___________________ Date ______________