FAX CONTRIBUTION

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Fax this form to 1-760-598-1114:

Audio Asylum
PO Box 626
Vista, CA 92083
760-598-8555
FAX: 1-760-598-1114

Please verify the information below one last time. The address must match your credit card billing address. If correct, simply complete the bottom portion of this form.

Moniker/Name:
Billing Information:

Primary Day Phone #:

Secondary Phone #:

Fax Phone#:

Credit Card Information:
Visa Mastercard Discover American Express
Exact Name on Card:
Number:	e.g., 5412-1234-5678-9012
Expiration Date:	/ e.g. 01/15
CVV Code:	e.g., 860, 3 digit number on back of card or 8609, 4 digit number on front of card (Amex)
Amount: (required, pick one)	Undiagnosed $US 25.00 Outpatient $US 50.00 Inpatient $US 100.00 (Excellent choice!) Certifiable Loon $US 250.00 Straight Jacket Club $US 500.00 Frontal Lobotomy $US 1,000.00 Fully Lobotomized $US 5,000.00 Other If Other, please specify in $US
Comments:

Moniker/Name:
Billing Information:
Primary Day Phone #:
Secondary Phone #:
Fax Phone#: