Payment Form

Your Information

*First Name:

*Last Name:

*Telephone:

*Address/Line 1:

Address/Line 2:

*City:

*State/Territory/Province:

*Zip/Postal Code:

*Country:

*E-mail Address:

Quantity

Type Inductees names in spaces below

(Maximum 10) Number of Inductee

Dinner Guests

Please enter the quantity of each dinner desired

Grilled Ribeye Steak

Chicken Basilica

Vegetarian Lasagna

Please note that the quantity dinners will equal the number of Inductees and Dinner guests

Area for additional information or instructions

Card Details

Card Information as displayed on bill (Needed for Owner Verification)

*First Name:

*Last Name:

*Address/Line 1:

Address/Line 2:

*City:

*State/Territory/ Province:

*Zip/Postal Code:


*Card Type
*Card Number	Please do not add spaces between numbers (16 digits)
*Security Code	3 digit code on back of card
*Expiration Date

Please Select the amount in table below that applies and enter it into the payment box at bottom of page.

There is a 3% Credit card Processing Fee with a credit card purchase. Questions Click Here.		Inductees @ $275.00 Each
		0	1	2	3	4
Dinner Guests @ *$95.00* *Each*	0		$283.25	$556.50	$849.75	$1,133.00
	1	$97.85	$381.10	$664.35	$947.60	$1,230.85
	2	$195.70	$478.95	$762.20	$1,045.45	$1,328.70
	3	$293.55	$576.80	$860.05	$1,143.30	$1,426.55
	4	$391.40	$674.65	$957.90	$1,241.15	$1,524.40
	5	$489.25	$772.50	$1,055.75	$1,339.00	$1,622.25
	6	$587.10	$870.35	$1,153.60	$1,436.85	$1,720.10
	7	$684.95	$968.20	$1,251.45	$1,534.70	$1,817.95
	8	$782.90	$1066.05	$1,349.30	$1,632.55	$1,915.80

If your needs do not fit in the table above please use formula below.

(# of Inductees x $275.00) + (# of Dinner Guests x $95.00) = (Subtotal x 3%) = Total Payment

I hereby verify that I am the Credit Card Holder and authorize the amount that I entered below to be charged against said credit card. I have read the UMAHoF Credit Card Policy Check the box if you understand and agree to these conditions.Yes

*Total Payment

$