Arizona United Rheumatology Alliance

Payment Information (must be made in U.S. dollars)

• -- Select Card -- Visa MasterCard American Express Card Type
• Name As It Appears on Card
• Credit Card Number
• Expiration Date (MMYY)
• Card Verification Number
• Billing Information
• Billing Street Address
• Billing ZIP Code

• Signature
• 
  Email Address
• 
  Telephone Number
• Signature Date
• I Agree that I represent and acknowledge that:

  1. I have read, understood, and consented to electronic delivery of the data collected and payment entered above.
  2. I have granted authorization to AURA in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided.
  3. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate.
  4. I intend the act of selecting “I Agree” to be my legal signature to this agreement.