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    IURPA Logo
    Credit Card Payment Form

    (Visa M/C and AMEX)

    2017 DUES ARE NOW BEING COLLECTED

    Please fill out the following information and press the SUBMIT button. If you do not feel safe submitting your Credit Card information over the Internet (quickest method), please feel free to down load a copy of the form, fill it out, and mail it in, or send it as an E-Mail attachment to the address on the form. You may down load the form from the link at the bottom of this page or from the main page.

    All fields with an asterisk (*) behind them require input in order to successfully complete the form.

Payment Type/Amount *
Dues Year/Period


Your Name *
Your Company
Address *
Address Line 2
City *
State *
Zip
Country *


Your Telephone
Your FAX
Web Site Address


Your E-mail * (For Verification)
Confirm E-mail * (For Verification)


Type of Company *


Credit Card Information:

Name As On Card *
Billing Address *
Billing City *
Billing Zip Code *


Card Type * (Visa, MC or AMEX)
Card Number * - - -
(Example: 0101-0202-0303-0404)

CV2 Number * (CV2)(3 or 4 Digit number from back of Card)
Expiration Date * (MO/YR)


It is strongly suggested that Non United States applicants use the "Comments" area below to show us your mailing address EXACTLY as it should appear on an envelope, and/or for general comments from anyone about anything.

This area is also to be used to explain any and all payments other than the standard selections listed at the top.


Comments:

If You Left Any "Required" Fields Blank, Back Up, Correct and Resubmit.

After clicking "Submit", Please Wait While Your Data Is Posted!










No 2 Energy Theft