Credit Card Draft Authorization
 
  -   -  
 Social Security Number
E-mail (No work email addresses please)
 
First Name
Middle Initial		  
Last Name
 
Mailing Address
 
City		  
County		  
State
 
Zip		  
Home Phone		  
Work Phone

 Member's Signature:  Date:

TERMS AND CONDITIONS:  I HEREBY AUTHORIZE my bank/credit card company to make my payment for membership dues to the Southern States P.B.A.I am aware that I retain  full control of my payment and that it will appear on my credit card statement.
 

Name on Credit Card:

Credit Card Type: 
 

Credit Card Number:

If you are using an American Express Card, please enter a 0 at the beginning of the card number!

  

     Expiration Date: 

Please complete this form,  print it, sign it, and then mail to:
Southern States PBA
P.O. Box 1898
McDonough, GA  30253

Phone: 800-233-3506