Book_of_the_Month_Order

Method of Payment

__Check - Check Number___________
(Make checks payable to MICPEL)

__Charge __Visa __Master Card __AMEX

CVV Number___________________________
(VISA & MasterCard last 3 digits on back of card)
(AMEX 4 digits on card front)

Account Number:___________________

Exp. Date____________________

Name on Card:_______________________

Please print or type all information clearly
Send or Fax to MICPEL - Credit Card required for fax registrations.

Please include information for

__change of address or
__different shipping address

Name:___________________________

Firm:____________________________

Street Address:________________________

City/State/Zip:_________________________

Phone:_______________________________

Fax:_________________________________

E-Mail:_______________________________