Family Federation for World Peace and Unification

Original Divine Principle Workshop, Aug. 6-10, 2009

Payment Form
Submit with payment by Sunday, July 26 via mail to FFWPU, 1510 Midway Ct.,
Unit E101, Elk Grove Village, IL 60007

                 

First Name Middle Name Family Name

Cash/Check Payment
Registration Fee: $500 (double-occupancy) Check No.:      __________ Date      ____________

$700 (single-occupancy)

Special Offering: $700 Check No.:      __________ Date      ____________

I pledge to pay the total Special Offering Fee through ______ (2-4) installments of $ __________ each on the following
dates (within 90 days); 1) __________ Check No.: ________________ , 2) __________ Check No.: ______________
3) __________ Check No.: ________________, 4) _________ Check No.: ________________

Credit Card Payment Visa MasterCard Discover Amex

Registration Fee: $515 (double-occupancy)

$721 (single-occupancy)

Special Offering: $721

I pledge to pay the total Special Offering Fee through ______ (2-4) installments of $ __________ each on the following
dates (within 90 days); 1) __________ 2) __________, 3) __________ , 4) __________

Credit Card Information

_________________________________________________________       __________
Credit Card No. Expiration Date

     _____________________________________________________________________________
Name as it appears on the Credit Card

      ________________________________________________________________________
Street Name and Apt. No.

      _________ ___________________

City State Zip Code

______________________________
Telephone

      __________________________________________________________
Memo

___________________________________
Paying For: if you are paying for someone else, please write the person’s name here

      _______________________________       __________

Signature Date