Credit Card Authorization

LAGOPCLUBS - Credit Card Authorization

Name *

First

Last

Cardholder Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Card Holder's Phone Number *

Cardholder's Email *

Membership Levels (Choose One) *

* Credit Card membership includes a 4% credit card processing fee.

Type of credit card (Select One) *

Credit Card # *

Credit Card Zip Code *

Credit Card Expiration Date (MM/DD/YR) *

Security Code (3-digit code on back of card) *

Security Code (4-digit for American Express Cards) *

I authorize LAGOPCLUBS/Beach Cities Republicans to charge the membership dues to my credit/debit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.

Cardholder Digital Signature *

* Once you hit submit, your credit card authorization will be received and we will process your credit within 24-72 hours after receipt. You will receive a email once we process your credit card.

Submit for processing