Pay Form

Asociacion Mundial de Mexicanos

en el Exterior.

150 N. Santa Anita Avenue

Arcadia, CA 91006

Spanish Tel: (626) 305-8477

English Tel: (626) 821-1805

Product or Service

Name

Address

Address (continued)

City and Sate

Zip Code

Country

E-mail address

Telephone

Card number

Security code

Type of card

Expiry date

Ticket, Registration,

Authorized Charge Amount $

Security Code

- Please fill out the form to sent your payment.

- In the address section, please write the address where your Bank

sends your monthly statement.

- Be sure to appropriate fill the product or service section

Made by AMME 626-305-8477