Nyx Donation Form

Print this form, fill it out, and mail to:

Nyx Net
P. O. Box 21586
Boulder, CO 80308-4586

Personal Information

Name   ___________________________________________________

Address   ___________________________________________________

City, State, Zip  ___________________________________________________

Nyx Username  ____________________________________

Credit Card Information

Donation Amount:   US$  _________________

Card Type:      ____Visa   ____Mastercard

Name on Card:    ___________________________________________

Account Number: ____________________________ Expiration Date_________

Automatic donation   ____Monthly    ____Bimonthly     ____Quarterly

Stop automatic payments on this date:__________________________

Signature: ______________________

Last updated 3 June 97