Please print this page, complete the information, and mail to trip leader.

I AUTHORIZE THE ADIRONDACK MOUNTAIN CLUB TO CHARGE MY CREDIT CARD ACCOUNT NUMBER:

___VISA Number  __________________________________ 

___MasterCard Number ___________________________________ 

___Discover Card Number _________________________________ 

___Am.Express Card Number _________________________________ 

Expiration Date:________________ 

$ ______________________ 

AS DEPOSIT/PAYMENT FOR: ADK Chaco Canyon Archaology.
In which I will participate on April 13 - 18, 2004
 

SIGNED: ____________________________________ Date: ___________________ 
 

NAME(please print):  _______________________________ 

Address: _________________________________ 

Phone/fax/e-mail: ___________________________________________________ 
 

SEND TO: Trip Leader: :    Mary Coffin   328 Deepsprings Dr., Chittenango, N.Y. 13037