Family Name: _________________________First Name:
__________________
Date of Birth (dd/mm/yyyy): _______/_______/______
(*NOTE: Date of Birth will NOT appear on mail-order ID
cards)
Mailing Address
Street: _______________________________________________ Apt #: ________
City: _______________________ State: ___________ Zip
Code: ____________
Telephone: (______ ) _______ - ____________
Email Address: ___________________________
Address to which you would like your card sent (If Different
From Above)
Street: _______________________________________________ Apt #: ________
City: _______________________ State: ___________ Zip Code:
____________
Telephone: (______ ) _______ - ____________
Credit
Card Number: |
______________________ |
Expiration
Date(m/y): |
______________ |
Cardholder's
Name: |
______________________ |
3
digit security code: |
______________ |
Billing
Address: |
______________________ |
(next
to signature bar on back of card) |
|
| |
______________________ |
|
|
| |
______________________ |
|
|
I certify the above information is true and accurate.
Signature:_____________________________Date: _______/_______/_______
- Print this application, complete and mail it to:
Travel
CUTS, 616 E Green St. Suite C, Champaign IL 61820, Attn: ID Dept.
- Include certified check or money order payable to Travel
CUTS for $28, plus cost of shipping method desired or include
Visa or Mastercard number.
|
