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- Type of Credit Card to Use (MC/VISA) :
- Credit Card Number :
- Credit Card Expiration Date :
- Your Full Name :
- Card Holder's Name (From Card Face) :
- Card Holder's Address :
- Card Holder's City or Town :
- Card Holder's State or Country :
- Card Holder's Zip or Postal Code :
- Card Holder's HOME Telephone Number :
- Card Holder's WORK Telephone Number :
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