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Credit Card Processing Slip

Name as it appears on Credit Card*

Credit Card Type (Please circle)

Card Verification Number* 3 digit code on back (last 3)

American Express

Card Verification Number* 4 digit code on front

Credit Card Number*

Billing Address

  • Same as Shipping Address

Expiration Date*

Phone

Email*

Signature*

X

Please note: After this order has been entered and payment authorized, this slip will be shredded to protect your financial data. Your credit card number WILL NOT be kept on record.

*Required

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