BNI Chapter 59
Visitor Payment Form
Order Summary
Order Date
Order Amount
$25
Description
BNI Chapter 59 - Visitor Meeting Dues
Meeting You Will Attend
If you are a member and are paying for your guest's fee, please include your guest's email here so that we may notify them you paid on their behalf.
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Checking Account Information
[hascreditcards]
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Account Holder Name:
Company Name:
Bank Routing Number:
Bank Account Number:
Drivers License Number:
Drivers License State:
Email Address:
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[creditcard]
Credit Card Information
[haschecks]
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Name as on Card
Company Name
Email Address
Card Billing Address
Card Billing Zipcode
Card Number
Card Expiration Date
Card ID (CVV2/CID) Number
(3 digits for Visa/MC/Disc, 4 digits for AMEX)
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