Association
1904 Coastal Highway, Suite C-7
Dewey Beach, DE 19971
Phone# 302-227-4011
Fax# 302-226-3407

I,_____________________________________of___________________give permission to SKIM USA to use the Credit Card Number for Telephone payment of Contest Entry Fee and/or Membership Fee for SKIM USA. All fees require a receipt that will be provided by SKIM USA to Credit Card Holder.

I,____________________________am releasing this information with the understanding that all fees paid with this Credit Card Number are final.

Contest Name___________________________________

Contest Date____________________________________

Card Holder_____________________________________

Address________________________________________

City_____________________________________

State_________________________Zip_________

Card Type ________MC _________VISA _______DISCOVER

Card Number____________________________________

Expiration Date________________Security Code (last 3 numbers on Reverse Side)__________

Signature_______________________________________

Date___________________________________________