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We are now able to accept credit cards. Print out this form, fill it in and fax it to the number shown below for a secure transaction. Name (as it appears on your credit card): _____________________________________ Billing Address: _____________________________________________________ City:__________________________ State:_______ Zipcode:_________-______ Phone #:_____________________________ VISA MASTERCARD AMERICAN EXPRESS (please circle one) Credit Card #:__________________________________________ Expiration Date:_____/______ Amount: $_____________________ Purpose of this payment: __________________________________ Signature:_________________________________ Date:_________________
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