remittance_of_funds-Membership-items

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A L P H A P H I A L P H A F R AT E R N I T Y , I N C .

®

| PO BOX 405478, ATLANTA, GA 30384-5478

Remittance of Funds Report – MEMBERSHIP ITEMS

Directions:

1.

Member should fill out form completely.

2.

Make check or money order payable to Alpha Phi Alpha Fraternity, Incorporated.

3.

Mail payments to PO Box 405478, Atlanta, GA 30384 -5478 or email to forms@apa1906.net for credit card payments.

4.

Keep a copy for your records.

5.

Please do not forget to include shipping and handling fees.

6.

A receipt will be sent upon request.

7.

Please allow 10-15 business days for items to be sent.

BILLING/SHIPPING INFORMATION Member Name:

Chapter Name:

Address:

City, State Zip:

Home Telephone:

Quantity Description

Account No. or S.S. Number:

Key Number :

Email Address:

Unit Price

S/H

Fraternity Pin

$110.50

$8.50

Dup. Life Member Plate

$27.50

$2.50

Duplicate Certificate

$23.00

$2.00

Duplicate Passcard

$5.00

$1.00

History Book Standard

$50.00 included

History Book Special Edition

$75.00

Total

included Balance Due

Shipping & Handling Fees

Add the S/H fee to the (quantity x unit price) in order to get the total. Any items not including shipping and handling fees will not be sent. PLEASE NOTE Phone: 1.800.373.3089 1. Only one ritual is allowed per Chapter. Email: forms@apa1906.net 2. The Ritual and Standing Orders can only be purchased by Alumni Chapter Presidents, College Chapter Advisors,

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tmp_YIQj4 updated 08/11/2009


CREDIT CARD PURCHASES VISA, AMEX AND MASTERCARD

FOR OFFICE USE ONLY FOR OFFICE USE ONLY TRANSACTION DATE: ______________

TYPE:

TRANSACTION PROCESSED BY:DATE: ______________ ______________

NUMBER: ______________________________________

PROCESSED BY:

EXP. DATE: ____________________________________

______________

_______________________________________


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