Credit Card Payment Authorization
for IMAWA products/services
This form MUST be completed in its entirety in order to process your credit card payment.
Company Name
Phone Number
(in case we have questions)
I authorize the Illinois Movers'
and Warehousemen's
Association to process payment
on my credit card for the
purchase of:
Brief Description of Product/Service:
Amount of Purchase:
SUBTOTAL $ ____________
Electronic Processing Charge: $ _____ 10.00
GRAND TOTAL DUE TO IMAWA $_____ _______
Name as it APPEARS
ON Credit Card:
Billing address as it APPEARS
ON Credit Card statement:
Credit Card Type
(check one: We accept ONLY
Visa or Master Card)
VISA Master Card
CREDIT CARD
NUMBER:
Expiration
Date:
_______________
CVV:
(3 digits on back
of card in
signature strip)
____________
Signature:
X
Date:
Thank you! We appreciate your business!
Illinois Movers’ and Warehousemen’s Association
Matthew W. Hart, Executive Director
• Adina M. Dunn, Member Services Director
932 South Spring Street • Springfield, IL 62704
Phone: 217-585-2470 • Toll Free: 888-791-2516
e-mail: imawa@imawa.com • internet: www.imawa.com
