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Online Course Mail Payment Form |
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Written by Nate Hardy, Internet Activities Coordinator
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If you must mail in your payment, print and complete this form then mail it with payment at least a week before the course starts to ensure timely processing:
Jackie Shaffmaster, Treasurer
Pennwriters
406 Second St.
Dalton, PA 18414
Course Title:
Date:
Pennwriters Member (Yes/No):
Payment $:
First Name:
Last Name:
Organization:
Billing Address Line 1:
Billing Address Line 2:
City:
State/Province:
Postal Code:
Country:
Telephone:
Email (required):
Payment Type (Visa/Mastercard/Discover/American Express/Check/Money Order):
Credit Card/Debit/Check/Money Order Number:
Card Expiration Date (Month & Year):
Credit/Debit Card Security Code (last 3 digits in signature area on back of credit card, or 4 digits on front of American Express card):
Signature:
If paying by check or money order, make payment to: “Jackie Shaffmaster”
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