Financial Agreement with Northern Division, USSA, 2012-2013 travel season

For the 2012-2013 travel season Northern Division will require a credit card number (American Express, Visa, or MasterCard only) or a $1000 deposit to be used by the Northern Division Manager when payments for Northern Division projects and races are not submitted in a timely fashion.  All paperwork is required in order to be placed on selection boards for the season.

It is understood that in order for an athlete to continue to receive Northern Division support at regional events their accounts must hold a zero balance.  If full payment is not made by the first day of a project/race series (including travel days), the Northern Division Manager will charge the credit card listed below or use my $1000.00 deposit that is included with this form. 

The Credit Card number will only be used by the ND manager when a check has not been received in the Northern Division offices by the start of the project.

Credit Card Information:

Name on Card: _________________________________________

Billing Address: _________________________________________


Phone number:___________________ E-Mail: __________________

Card Number :____________________________________________

Expiration Date: _____________ Security Code (3 digits): __________

With my signature I agree to pay for any unpaid race expenses if payment has not been received by Northern Division USSA by the first day of the project, including travel days.  By allowing the use of my credit card that I have provided to Northern Division above I also agree to the addition of the 4% surcharge to cover extra banking expenses incurred by Northern Division.  Once the credit card is processed, I will receive a statement from Northern Division showing the exact amount charged to my credit card listed above.

Signature: __________________________ Date: ________________

Please send to:  USSA Northern Division, P.O. Box 217, Whitefish, MT 59937 or fax to 406.545.2289