VISA/PAYPAL PAYMENT FORM to fill out AFTER you already paid through Paypal!
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
TODAY's   DATE:
DEPOSIT:
Visa/Paypal Form 
When Deposit/Payment Is COMPLETED !		 $       . DOUBLE ROOM 
               SINGLE   ROOM(additional amt.) 
RESERV. FOR  THIS  NO. OF PERSONS  ..
Additional Comments: .
. Clear Form Info.
.
 .. ....This will send your info by Email to Judy...
(You will get another window in your browser....Press SEND or OK)
Fill in form above after you make the payment through PAYPAL
1. Press the Submit  by Email button with all your information. (You should hear from me within 24 hours).
 
2. OR please print the above form and fax it to me or mail by US post office

                            3. OR ....if you cannot print it, then copy information and send in to:

 Send deposit to:
    POLKA AMBASSADOR CLUB
      205 OTTO ST
                    BELLE VERNON, PA 15012
                                                            Judy     1-724-929-6019      email:  judi@stringhill.com
                           FAX 1-724-929-6019