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SECURE PAYMENT FORM

This is our secure credit card payment from. Please fill out ALL REQUIRED ITEMS.

CREDIT CARD NUMBER*

EXPIRATION DATE*

NAME OF CARDHOLDER*

CREDIT CARD SECURITY CODE*

SIGNATURE *

AMOUNT TO BE CHARGED*

YOUR BILLING ADDRESS*

CITY, STATE, ZIP*

YOUR PHONE*

YOUR EMAIL ADDRESS*

SHIP TO ADDRESS

CITY, STATE, ZIP SHIP TO