DO NOT SEND PAYMENT DATA OVER THE INTERNET!  Print this form, complete as requested and fax or send to Upper Midwest Chapter office:
		NATAS-MN
		4967 Kensington Gate
		Shorewood, MN  55331
		Fax:  952-474-7370

Emmy entries may be paid by company check, personal check, purchase order or VISA/MasterCard.

Company or Personal Check:
* Please enclose check with Official Entry Form(s) and send with tape(s).  
* When a SINGLE CHECK covers MULTIPLE ENTRIES, a list of all entries covered MUST accompany the check.

Purchase Orders:
* Purchase Orders must be signed
* Purchase Orders must be drawn to:
NATAS-MN
4967 Kensington Gate
Shorewood, MN  55331
Federal Tax ID/EIN:  41-1972581
* Please enclose Purchase Order with Official Entry form(s) and send with tape(s).

VISA or MasterCard:
* Please complete form, below.  Enclose with Official Entry form(s) and send with tape(s).
* When credit card covers multiple entries, a list of all entries covered MUST accompany this form.  You may use the back of this form.

Card Holder Name:

Card Holder Street Address

Card Holder City, ST, ZIP

Card Holder email				

Card Holder Daytime Telephone

VISA or Mastercard Card Number:
        -         -         -         

Expiration Date			Total Amount $

Card Holder Signature