First Year Camper

Credit Card Form
Credit card payments incur a 3% nonrefundable convenience fee. There is no charge
for payments made by personal, business or bank checks.
To make a credit card payment (Visa or Mastercard), please complete this form and mail
it or fax it to our New Jersey Office.
CAMP LOHIKAN
P.O. Box 189
Gladstone, New Jersey, 07934 USA
Fax 908-470-9319
Camper's Name ________________________________________________________
Address _______________________________________________________________
Amount to be charged (3% will be added) ____________________________________
Please apply payment to:
__ Initial Deposit
__ 2nd Payment
__ Balance Payment
__ Other Please specify:_______________________________________________
If the payment is being made for extra program charges (i.e., paintball, golf trip, etc.),
please include the applicable permission form.
CREDIT CARD INFORMATION
Card Holder's Name _____________________________________________________
Card Holder's Telephone/Cell Number__________________
CARD TYPE: Visa___________ Mastercard ________
Card Number ___________________________________________________________
Expiration Date (mm/yy) ______________________________
Card Holder's Signature___________________________________________________
Today's Date ________________________________