Bergeys Manual Trust
Secure Payment Form

 
Order Summary:
Order Date: 04/20/24
Select Membership:

           
Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode/Postal code:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
 
[What is the Card ID?]
   
Member Information:
Title:

First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip/Postal code:
Country:
Phone Number:
Email Address:
     
Degree in progress:
Degree-granting Institution:
Subject:
Head of your Department*:
*Important note: Head must write a brief supporting letter verifying that you are in their department. Submit the letter by mail to BISMiS, 527 Biological Sciences Building, University of Georgia, Athens GA 30602-2605, USA, or by email to bergeys@uga.edu.
Notes: