Would you like to sign up for Automatic Dues Renewal? (Please Note: your credit card's expiration date must be past your renewal date next year to be eligible for this offer) *
Terms of the Agreement I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Christian Medical & Dental Associations in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next transaction date. If the noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
I hereby authorize Christian Medical & Dental Associations to obtain or determine updated or replacement expiration dates for your credit card in the event that the credit card you provided us expires. We reserve the right to charge any renewal card issued to you to the same extent as the expired card.
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Your credit card will be processed within seven business days by our accounting department at which time you will receive an email showing the amount charged to your credit card.
Credit Card Expiration Date * - Month - January (01) February (02) March (03) April (04) May (05) June (06) July (07) August (08) September (09) October (10) November (11) December (12)
- Year - 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 (?)
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Country for Credit Card * --Select-- UNITED STATES OF AMERICA AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOTSWANA BRAZIL BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA CONGO CONGO, DEM REP (KINSHASA) CONGO, REP (BRAZZAVILLE) COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FAEROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEM PEOPLE'S REP KOREA, REPUBLIC OF (S) KUWAIT KYRGYZSTAN LATVIA LEBANON LESOTHO LIBERIA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA, FED STATES MOLDOVA, REPUBLIC MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NORFOLK ISLAND NORTHERN IRELAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINE PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RWANDA SAINT KITTS AND NEVIS SAINT LUCIA SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA ST VINCENT AND GRENADINES SUDAN SURINAME SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC THAILAND TOGO TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, US WALES YEMEN ZAMBIA ZIMBABWE (?)