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Payment

Payment Summary

Based on your selections, there is no payment due at this time.

Please click the 'Process' button to complete your submission.

Total:

This form allows partial payment with a minimum of .

Amount to pay: $

Remaining Balance:

Credit Card/Name - Payment Method

Card Number*

Expiration*

Security Code*

Name on card*

Optional email address(es) where we should send a payment receipt. (Separate multiple email addresses with a semicolon)

Address*

City*

State*

Postal Code*

* Indicates a required field

I authorize to collect $0.00 from my account. I hereby authorize to collect from my account the above amount. By checking the box I acknowledge that my account () will be stored and charged as outlined above. Payment is to be made when billed in accordance with the standard policy of the account holders bank. If I need to request a refund, I agree to contact as soon as possible to make the request, knowing that there may be circumstances that prevent such a refund from being made.

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Submission ID: JIM
Confirmation code: JIM

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Jim Smith