Automatic Payment
From Your Credit Card

TERMS OF AGREEMENT

I am authorizing Macular Degeneration Research (MDR) to charge my credit card account monthly in the amount of the pledge I have indicated. This agreement will remain in effect until I have given MDR at least thirty (30) days written notice of its termination. A record of each gift will appear on my credit card statement and will serve as my receipt.

 

Credit Card:

[ ] VISA

[ ] MasterCard

[ ] American Express

[ ] Discover

Automatic payment amount: $___________________________________
Credit card #: ____________________________________
Security code # (Need Help?) ____________________________________
Expiration date: ____________________________________
Signature: ____________________________________
Date: ____________________________________

 

Please complete the following information:

Name: ____________________________________
Address: ____________________________________
City/State/Zip: ____________________________________
Phone: ____________________________________
E-mail: ____________________________________

Because this agreement may take a few weeks, please be sure to make this month's pledge contribution with your personal check. Thank you!

 

Macular Degeneration Research
22512 Gateway Center Drive
Clarksburg, Maryland 20871
1-800-437-2423

 

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How To Locate Your Security Code

 

 

 

 

 

 

 

Visa and MasterCard

  1. View the back of the credit card.
  2. The security code will be the last three digits listed after your credit card number.
  3. Although almost all cards now have the 3 digit security code, if your card does not have one, please enter three zeros.

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American Express

  1. View the front of the credit card.
  2. The security code will be the four digits that are above and to the right of the credit card number.
  3. Although almost all cards now have the 4 digit security code, if your card does not have one, please enter four zeros.

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Discover

  1. View the back of the credit card.
  2. The security code will be the last three digits listed after your credit card number.
  3. Although almost all cards now have the 3 digit security code, if your card does not have one, please enter three zeros.

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