FAX

***** 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
PO Box 5485
Pittsburgh, PA 15206 USA

or to guide you when leaving the information on our phone at 
(412) 436-5558.  "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           --  $ 39.95
             One year membership          --  $ 69.95
             Three year membership        --  $179.95

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

Card number:       ____________________________________

Expiration date:   ____________________________________

Full name on card: ____________________________________

Billing address:   ____________________________________

                   ____________________________________

                   ____________________________________

Phone number:      ____________________________________



Signature: _____________________________