Use this form to pay for your Internet Chess Club membership by FAX. Use your web browser to print this page. Fill out the form and FAX to

You can also use this form for paying by postal mail (ICC, Internet Chess Club, 5820 Forbes Avenue, Suite 1, Pittsburgh, PA 15217 USA), or to guide you when giving us the information over the phone (412-521-5553).

All information below is required.

ICC handle: __________________________

Choose one of the following four membership options:

Three month membership	--	$24.95
Six month membership	--	$39.95
One year membership	--	$69.95
Three year membership	--	$179.95

If you are applying for additional time because you are a student, include your age or proof of student status.

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

Card number:       ____________________________________

Expiration date:   ____________________________________

Full name on card: ____________________________________

Billing address:   ____________________________________

                   ____________________________________

                   ____________________________________

Phone number:      ____________________________________



Signature: _____________________________