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___ Check (full payment required when paying by check)
____VISA ___MATERCARD ____DEBIT
___Full Annual Payment ___Quarterly Payment ___Monthly Payment
Name on Charge Card____________________________________________________________
Charge Card #__________________________________________________________________
Expiration Date___________________ 3 digit CVB Code____________
For debit payment only:
Bank Name_______________________________________________________________
Account #_________________________________________________________________
Authorization Signature:_______________________________________________________
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