Faxable Credit Card Form
To complete your registration, please completely fill out the following form.
Name
Screen Name
Name on card (If different from above)
Credit Card Type (Circle one)	VISA       MASTERCARD
Credit Card Number
Expiration Date
Phone Number
Email Address
By signing below, I authorize Midwest Recreational Clearinghouse to charge the credit card number listed above a maximum of $1500.00 USD if I do not pay for an auction item within 5 (five) days of winning said item. In addition, I further authorize Midwest Recreational Clearinghouse to charge up to $1500.00 USD if I convey either in writing, verbally or through email, to Midwest Recreational Clearinghouse that I fully intend on not purchasing a unit that I am a high bidder on when the reserve has been met.
Signature:   ________________________________________________________ Date:          ________________________________________________________
Once the form is complete, print it out and fax it to 507.263.9434