Dublin Youth Athletics
Credit Card Authorization Form

mastercard.gif (1929 bytes)

 visa.gif (1604 bytes) wpe2.jpg (11271 bytes)
Card Used (Circle one)

       MasterCard

      Visa

        Discover
Name of Cardholder
(Exactly as it appears on the card)		 _______________________________________________________
Card Number _______________________________________________________
Expiration Date _______________________________________________________
Name(s) of Player(s) signed up _______________________________________________________
Amount Charged  $ _______________________________________________________
Authorized Signature ________________________________________Date___________