 Please cut along the dotted line, complete, and return the form below to VCI   - - - - - - - - -
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  * Recurring charges are billed to credit card on the last business day of the month. Statements will not be mailed for these charges. | |||
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TO CHARGE YOUR PAYMENT TO YOUR CREDIT CARD | |||
| Please check one: VISA _______ | MASTERCARD _______ | ||
| CREDIT CARD ACCOUNT NUMBER | EXPIRATION DATE | ||
| RECURRING AMOUNT $ ____________ | OR ONE TIME AMOUNT $___________ | ||
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MUST BE SIGNED TO BE VALID | |||
| PRINT CARDHOLDER NAME | |||
| Signature | |||
| Address | |||
| City | State | Zip | |
| Today's Date | YOUR VCI ACCOUNT NUMBER | ||