Melinda's Pension Fund

If you prefer to send a contribution using a credit card, you may do so by filling in the form below.

 Visa/MC/Amex/Discover - credit or debit card payment

Card Number: __________________________  Exp (mo/yr): _______

Card Verification Number: _________
(the 3-4 digit number on the back of VS/MC/DS and front of Amex cards - see examples below)

Select Payment Frequency and Amount:

(  ) One Time Payment - Amount: $_______
(  ) Automatic Recurring Payment (monthly) - Amount: $_______
Select date debited: (  ) 1st day OR 15th day (  )

Signature: _______________________________________________________________

Printed Name as on Account: _______________________________________________

Account Statement Mailing Address: _________________________________________

________________________________________________________________________

________________________________________________________________________

Send to Subud USA, 14019 NE 8th ST #A, Bellevue, WA 98007; fax 425-643-2725
Examples of Card Verification Numbers