June - November 2010 MLS Fee Payment Form

ALL FIELDS ARE REQUIRED. PLEASE USE YOUR CREDIT CARD BILLING ADDRESS BELOW, NOT YOUR COMPANY ADDRESS.

Member #		Member # located on your bill in the box to the right of your name
First Name
Last Name
Company
Credit Card Billing Address
City
State	Choose From List N/A - International Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Country	United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia And Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands, The Cape Verde Caribbean Cayman Islands Central African Republic Chad Channel Islands Chile China, People's Republic Colombia Comoros Congo Congo, The Democratic Republic of Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic, The Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Republic Guinea-Bissau Guinea-Equatorial Guyana (British) Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland, Republic Of Islas Malvinas Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Korea, The D.P.R of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya (Libyan Arab Jamahiriya) Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru, Republic Of Nepal Netherlands Antilles Netherlands, The Nevis New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norway Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines, The Poland Portugal Puerto Rico Qatar Reunion, Island Of Romania Russian Federation, The Rwanda Saipan Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland, Rep of (North Somalia) South Africa Spain Sri Lanka St. Barthelemy St. Croix St. Eustatius St. John St. Kitts St. Lucia St. Maarten St. Thomas Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Thailand Togo Tonga Tortola Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Yemen Zambia Zimbabwe
Zip/Postal Code
Phone
Fax
E-mail (required)
Payment Amount:   As of 7/16/2010     Book Total $900.00             No Book Total $565.00             ** When entering payment information, please confirm your address entered matches where your credit card is registered (i.e. home address is provided for home credit card, work address is provided for work credit card).