Membership Recurring Credit Card Form

Company*

Name of Submitter*

First Name

Last Name

Email*

Phone*

Invoice Number*

Invoice Total* $

AMEX USERS: Please do not exceed an online payment total of $5,000. For more information, contact our finance team at 317.464.2222.

CREDIT CARD INFORMATION

Card Number*

Name on Card*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Acknowledgement of Recurring Billing

I acknowledge and understand that by checking this box, my organization is enrolling in the Indy Chamber's recurring billing structure. The credit card listed above will be charged the total membership dues amount on an annual basis beginning the date this payment is processed unless membership is changed or cancelled. Your organization will receive a notification 30 days prior to your renewal date as a reminder of this annual charge.