PSA Order Processing Center

Form for Purchasing Copies of Records from the Polish State Archives

By VISA or MasterCard

Please note: This form must be accompanied by all the Jewish Vital Records Order Forms that are being paid for by this credit card transaction.

JRI-Poland PSA Order Processing Center does not accept credit card transactions over the Internet, by fax, or by telephone. Please mail your Order Forms to:

JRI - Poland PSA Order Processing
PO Box 146
Merion Station, PA 19066
USA

Please complete all sections of this form.

Visa [ ] MasterCard [ ]
Name as it appears on Credit Card _________________________________

Signature ______________________________________

Credit Card Number________________________________

Expiration Date_________________________
(NOTE: This form is for VISA and MasterCard credit cards only.)

Amount of Order in US$_______________
Must agree with the total of all orders mailed with this form.

Billing Address of Credit Card

Street and House Number______________________________

Apartment or Flat Number_____________________________

City_________________________________________________

State/Province_______________________________________

Zip/Postal Code______________________________________

Country______________________________________________

Email Address________________________________________

Home Address (if different from Billing Address above)

Street and House Number______________________________

Apartment or Flat Number_____________________________

City_________________________________________________

State/Province_______________________________________

Zip/Postal Code______________________________________

Country______________________________________________

Home Phone___________________________________________