RAIDERS BALL HOCKEY VISA/MASTERCARD AUTHORIZATION:

     Purpose: Pre-Season Tournament Payment

     Team Name: ____________________________________________ Division: _________

     Name on Credit Card: __________________________________ Tel: ________________

     Visa            MasterCard

Card Number: _________________________________ Expiry Date (month/year): ______

Amount to be charged to card (Canadian dollars):  $525.00

Authorized Signature: ______________________________________

Today’s Date: ___________________________________

Please print, fill in above and fax to 604-570-0100

Your e-mail address (for confirmation purposes): _________________________________

Thank you,

Fernando Alves

Raiders Ball Hockey