ICC Help: FAX

Use this form to pay for your Internet Chess Club membership
by FAX.  You can email this form to yourself by typing

          mailhelp FAX

and then print it out.  Fill out the form and FAX to

         (412) 521-5575  (USA)

You can also use this form for paying by postal mail

Internet Chess Club
5820 Forbes Avenue, Suite 1
Pittsburgh, PA 15217 USA

or to guide you when leaving the information on our phone at 
(412) 521-5553.  help fees on ICC gives complete details.  
You can also pay online using the "extend" command.  

All info below is required.

ICC username: __________________________

Membership type (choose one):
             6 month membership           --  $ 34.95
             One year membership          --  $ 59.95
             Three year membership        --  $149.95
             One year student membership  --  $ 29.95

(For the student membership, include proof of student status, or age.)

Type of credit card (circle one): Visa  Mastercard  Amex

Card number:       ____________________________________

Expiration date:   ____________________________________

Full name on card: ____________________________________

Billing address:   ____________________________________

                   ____________________________________

                   ____________________________________

Phone number:      ____________________________________

Signature: _____________________________