| CMDA accepts
MasterCard,Visa and American
Express |
| GHO
Payment/Donation |
|
Name of Trip
Participant(s):
|
|
|
Trip Location(s) and
Date(s):
|
|
|
Email Address of person
making payment:
|
|
|
Phone number of person
making payment:
|
|
|
Enter the amount of
payment WITHOUT COMMAS (Example: 1000.00):
|
|
|
Card Number (Enter space
between numbers - Ex. 1111 1111 1111 1111):
|
|
|
Expiration Date
(mm/yyyy):
|
|
|
Exact Name on Card of
person making payment:
|
|
|
Billing Address for Card
of person making payment:
|
|
|
Billing Address 2 for Card
of person making payment (if needed):
|
|
|
Billing City of person
making payment:
|
|
|
Billing State of person
making payment:
|
|
|
Billing Zip of person
making payment:
|
|
|
Phone Number of person
making payment:
|
|
|
List Names and amount per
person if paying for multiple applicants:
|
|
|
|