U.S. Army Corps of Engineers Annual Pass Purchase by Mail

Name

Address_____________________________________________________

City_________________________________________________________

State___________Zip____________________

Phone #( ) ________________________

Item

Cost

Due

Annual Vehicle Pass

$30.00

Senior/Access Pass Holders

$15.00

Total Amount Enclosed ____________

Payment Method

___ Check or Money Order Payable to: FAO USAED Rock Island

___ Master Card ___ Visa ___ Discover ___ Diner's Club ___ American Express

Card Number

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Expiration date: (MM/YY) ______________/_______________ *Security/V-Code __ __ __ __

* V-Code: the last grouping of 3 or 4 numbers located on the back of your credit card in the signature line.

_______________________________________________________

Authorized Signature Credit Card Holder

NO REFUNDS

Mail To: Saylorville Lake

Attn: Day User

5600 NW 78th Ave

Johnston, IA 50131

OFFICIAL USE ONLY

Pass # ___________________________

CR Receipt # _____________________

Date Mailed ______________________

Issued By ________________________