Eating Disorder Referral and Information Center

International Eating Disorder Referral Organization

PAY BY SECURE FAX PAGE - YOU MUST USE THIS FORM

You can print this page and then fax the following information to our private fax: 858-220-7417

First Name on card:

Last Name on card:

Card Type (circle one): Visa, Mastercard, American Express, Discover

Card Number:

Expiration Date:

Card Verification
Number:
(On the back of your card, locate the final 3 digit number--4 digits for AMEX)


Address on your card billing statement:

City:

State:

ZIP Code (5 or 9 digits):

I verify that the address listed above is the same as the billing address for the credit card YES/NO (circle one).

Contact phone number (and name if different than above) in case there is an issue with the credit card:

Optional: Include an email address where we can send a receipt:
(we will do our best to send a receipt to the email addresses we have on file)

What amount do you expect to be charged to your credit card? (if you want us to calculate the amount, then indicate that here) $_____________ (SEE PREVIOUS PAGE FOR PAYMENT OPTIONS)

(we do not recommend sending this information by email)

Fax: 858-220-7417

You could instead decide to mail a check made out to EDRIC at 2923 SANDY POINTE STE 6 DEL MAR CA 92014

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