Method of Payment

_____ Enclosed is a check payable to KLCEA

_____ Purchase Order  # ________________________________________

_____  Credit Card (See below)

 

Name____________________________________________________

Address___________________________________________________

_________________________________________________________

E-mail address_____________________________________________

Telephone:________________________________________________

 

For Credit Card Payments

Name on Credit Card ______________________________________

Billing Address ___________________________________________

________________________________________________________

 Credit Card #________________________________ Expiration Date _____________

 

Please print this form and mail or fax it to the address or fax number below:

Melissa Freeman
Maine Department of Agriculture
28 State House Station
Augusta, ME  04333-0028
Telephone:  207-287-1132
Fax:  207-624-5040