Latinos Unidos Member Application

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Latinos Unidos Record Pool
136 Locust Avenue
North Arlington, NJ 07031
(201) 998-2377 Office
(201) 998-2677 Fax
www.LatinosUnidosOnline.com
kmokato@aol.com

To Latinos Unidos Record Pool, I __________________________________________
Authorize you to charge my credit card the monthly dues on a monthly basis until further notice by letter or call.

1) Credit Card Name__________________________________________________

2) Name on Credit Card_______________________________________________

3) Credit Card #_____________________________________Exp Date_________

4) Address:______________________________________City:________________

5) State:______________________________________Zip Code:______________

6) Signed:______________________________Date_________________________

Thank You,

William Otero