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<html>
<head>
<title>GCAT Membership Renewal Form</title>
<style type="text/css">
<!--
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#Layer1 {
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	width:545px;
	height:139px;
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<body>
<img border="0" src="../images/tigerrun.gif" align="left" width="69" height="45">&nbsp;<font face="Verdana" size="2"><a href="../../"><img src="../_derived/home_cmp_romanesquetx110_gbtn.gif" width="95" height="20" border="0" alt="Home" align="middle"></a> <a href="2006_Natl_conf.htm"><img src="../_derived/up_cmp_romanesquetx110_gbtn.gif" width="95" height="20" border="0" alt="Up" align="middle"></a> <a href="../feedback.htm"><img src="../_derived/feedback.htm_cmp_romanesquetx110_gbtn.gif" width="95" height="20" border="0" alt="Feedback" align="middle"></a> <a href="../toc.htm"><img src="../_derived/toc.htm_cmp_romanesquetx110_gbtn.gif" width="95" height="20" border="0" alt="Contents" align="middle"></a> <a href="../search.htm"><img src="../_derived/search.htm_cmp_romanesquetx110_gbtn.gif" width="95" height="20" border="0" alt="Search" align="middle"></a> <a href="../news.htm"><img src="../_derived/news.htm_cmp_romanesquetx110_gbtn.gif" width="95" height="20" border="0" alt="News" align="middle"></a></font>
</p>
<p align="center"><font face="Verdana" size="1"><img src="../images/membership-renewal-header.gif" width="600" height="60" border="0" alt="Online Registration"></font></p>
<h2 align="center" class="style1"><br>
  <br>
</h2>
<div id="Layer1">
  <h2 align="left" class="style1">Governmental Collectors Association of Texas </h2>
  <h3 align="left">Yearly Calendar Dues Renewal Application (All Member Types) <strong><br>
  </strong>Cost: $50.00 </h3>
  <p align="left">To renew your membership with GCAT, please complete the renewal   application below.&nbsp; For further information or should you have any questions,   please contact the current GovCAT President or Treasurer.</p>
  <p align="left">&nbsp;</p>
</div>
<p><br>
  
  <!--<FORM action="https://test.authorize.net/gateway/transact.dll">--!>
<!-- Uncomment the line ABOVE for test accounts OR the line BELOW for LIVE accounts-->
<FORM action="https://secure.authorize.net/gateway/transact.dll">
  <input type='hidden' name='x_description' value='Membership Renewal Application' style='width:300;'>
<br><input type="text" name="x_fp_sequence" value="285" style="width:300;"> x_fp_sequence
<br><input type="text" name="x_fp_timestamp" value="1219889870" style="width:300;"> x_fp_timestamp
<br><input type="text" name="x_fp_hash" value="ae7617918523cd0b037d0e7a0c917bf6" style="width:300;"> x_fp_hash
<br><input type='hidden' name='x_login' value='GOVERMENT9' style='width:300;'>
<br><input type='hidden' name='x_amount' value='50' style='width:300;'>
<br>
  
  <INPUT type="hidden" name="x_show_form" value="PAYMENT_FORM" style="width:300;">
  <br>
  <INPUT type="hidden" name="x_color_background" value="#eeeeee" style="width:300;">
  <br>
  <INPUT TYPE=HIDDEN NAME="x_method" VALUE="CC">
  <INPUT TYPE=HIDDEN NAME="x_type" VALUE="AUTH_CAPTURE">
  <INPUT TYPE=HIDDEN NAME="x_relay_response" VALUE="TRUE">
  <INPUT TYPE=HIDDEN NAME="x_logo_url" VALUE="http://www.govcat.net/images/gcat-logo.gif">
</p>
<td width="18%"><table width="100%" border="1" cellpadding="2" cellspacing="0" bordercolor="#0000FF">
  <tr>
    <td colspan="2" bgcolor="#0000FF"><span class="style4">Card Holder/Primary Contact Information</span></td>
    </tr>
  <tr>
    <td><strong>Name of Organization:</strong></td>
    <td><input type=TEXT name="x_company" size="50" /></td>
  </tr>
  <tr>
    <td><strong>First Name:</strong></td>
    <td><input type=TEXT name="x_first_name" size="50" /></td>
  </tr>
  <tr>
    <td><strong>Last Name: </strong></td>
    <td><input type=TEXT name="x_last_name" size="50" /></td>
  </tr>
  <tr>
    <td><strong>Title:</strong></td>
    <td><input type=TEXT name="cardholder_title" size="50" /></td>
  </tr>
  <tr>
    <td><strong>Address:</strong></td>
    <td><input type=TEXT name="x_address" size="60" /></td>
  </tr>
  <tr>
    <td><strong>City:</strong></td>
    <td><input type=TEXT name="x_city" size="40" /></td>
  </tr>
  <tr>
    <td><strong>State:</strong></td>
    <td><input name="x_state" type=TEXT size="5" maxlength="2" /></td>
  </tr>
  <tr>
    <td><strong>ZIP:</strong></td>
    <td><input type=TEXT name="x_zip" size="10" /></td>
  </tr>
  <tr>
    <td><strong>Business Phone: </strong></td>
    <td><input type=TEXT name="x_phone" size="25" /></td>
  </tr>
  <tr>
    <td><strong>Business Fax: </strong></td>
    <td><input type=TEXT name="x_fax" size="25" /></td>
  </tr>
  <tr>
    <td><strong>Reply to Email: </strong></td>
    <td><input type=TEXT name="x_email" size="70" /></td>
  </tr>
  <tr>
    <td bgcolor="#0000FF">&nbsp;</td>
    <td bgcolor="#0000FF"><input name="submit" type="submit" value="Continue to Payment Form"></td>
  </tr>
</table>
  <p class="style1"><strong><a href="http://www.authorize.net" target="_blank"><img src="../images/authorize-net.gif" alt="Secured Payment System - Authorize.net" width="150" height="35" border="0" align="absbottom"></a> </strong>By clicking the &quot;Continue to Payment Form&quot; button above you will redirected to our secure payment authorization site. Please make any necessary changes on this page before submitting payment. Shipping Information fields are included by default and may remain blank. An optional Level 2 Purchase Order information field may be filled for your records. </p>
</body></html>