Online Order Form - Capital Region Golf Card
         
Billing Address:      
First Name:    
Last Name:    
Street Address:    
   
City:    
State:    
Zip:    
  Phone:    
  Fax:    
  Email: Required!!!!    
         
Shipping Address: check here if shipping to the billing address    
  First Name:    
  Last Name:    
  Street Address:    
     
  City:    
  State:    
  Zip:    
         
Quantity:      
  One Capital Region Golf Card - $24.95 ($29.65 w/ tax and shipping)    
  Two Capital Region Golf Card - $49.90 ($56.60 w/ tax and shipping)    
  Three Capital Region Golf Card - $74.85 ($83.54 w/ tax and shipping)    
  Four Capital Region Golf Card - $99.80 ($110.49 w/ tax and shipping)    
  Five Capital Region Golf Card - $124.75 ($147.61 w/ tax and shipping)    
       
  Credit Card Information:      
  Card Holder Name:    
  CC#: (1111 2222 3333 4444)    
  Exp. Date: (MM/YYYY)    
  CC Billing Address: check here if CC billing address is the same as the billing address above    
  Street Address:    
  City:    
  State:    
  Zip:    
  CC Type: VISA MasterCard AMEX    
  CIN Number: 3 digit CIN for VISA/Master Card (bakc of card) or    
    4 digit CIN for AMEX (front of card)    
         
  How did you hear about the Capital Region Golf Card?    
    Newspaper TV Radio Friend Golf Course Internet    
    Store    
         
  Did you purchase the Capital Region Golf Card for:    
    Yourself Gift    
       
     

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