CC authorization

 

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THE HUMAN ADVENTURE CORPORATION

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COMMUNION AND LIBERATION

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CREDIT CARD AUTHORIZATION

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Please fill out the form and return it by email as a PDF file to medconference.aamp@gmail.com

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CARDHOLDER INFORMATION CREDIT CARD INFORMATION

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Credit Card #

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Cardholder Name

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Expiration Date

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Billing Address

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Security  Code

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City/State/Zip

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[visa]    [mastercard]    [amex]    [discover]

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Billing Telephone Number

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AUTHORIZATION

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Email I hereby allow the Human Adventure Corp. to charge

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my credit card in the specified amount.

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PAYMENT

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Payment for: MEDICAL CONFERENCE 2011 Print Name

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Amount:          $ Date

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MAILING ADDRESS, IF DIFFERENT FROM ABOVE

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Name

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Home Address

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City/State/Zip

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  125 Maiden Lane, 15th Floor – New York, NY 10038

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