LCAA Dues Payment

First Name:
Last Name:
Please comfirm your information for the directory:
Company:
E-Mail:
Phone Number:
Membership Level: Click Here for more info on levels.		Please Select Silver ($50) Gold ($250) Platinum ($500) Legacy Circle ($1000)
Tax deductible contribution to Cobb Youth Leadership		$ 0 10 25 50 75 100 150 200 250 Sponsor Half Tuition $350 Sponsor Full Tuition $700
Tax deductible contribution to Leadership Cobb		$ 0 10 25 50 75 100 150 200 250
Total (Dues + Optional Contribution)		$	**only input    numerical values
PLEASE make sure the numbers above are correct. Do not allow auto-fill values. Your credit card will be charged the above amount.
Would you like to enroll in automatic annual renewal?
Yes, I agree to allow an automatic charge annually for the above mentioned amount.         I understand this will occur annually until I notify the Cobb Chamber to cancel.
Not at this time.
Credit Card		MastercardVisaDiscoverAmex
Credit Card Number:               Name On Card Security Code Valid Through 01 02 03 04 05 06 07 08 09 10 11 12 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Credit Card Address 1 Credit Card Address 2 Credit Card City Credit Card State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NS NT NU ON PE QC SK YT AG BN BS CH CL CM CP DF DU GR GT JA MC MR MX NA OA PU QE QR SI SL SO TB TL TM VE YU ZA Outside US Outside Canada Outside Mexico Credit Card Zip Credit Card ZipExt Credit Card Phone Number Credit Card Country Credit Card Email Address
Please click submit only one time.  The transaction may take several seconds.