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PAYMENT AUTHORIZATION

First Name on Card*

Last name on Card*

Email*

Phone*

Billing Street Address*

Billing City*

Billing Zip Code*

Credit Card #*

Enter full credit card number

Confirm Credit Card #*

Re-enter full credit card number

Expires Month*

Year Expires*

Sec Code*

I AUTHORIZE A MONTHLY DUES FEE OF $35 CHARGED TO THE CREDIT CARD PROVIDED. I UNDERSTAND THIS FEE IS RECURRING AND NON-REFUNDABLE BUT MAY BE CANCELED ANY TIME.

Signature

Date picker*

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