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Name_____________________________________________
Company Name____________________________________
Address___________________________________________
City / State / Zip ____________________________________
Phone ____________________________________________
Payment Option . . .
_____ Bill me
_____ Payment enclosed for $_____________________
_____ Charge to . . . _____
Visa _____ Mastercard
Card Number ______________________________________
Expiration Date ________________
If responding to a promotion please note which FREE
issue you would like to receive_________________________ |
_____ Guarantor
$1,000+
_____ Benefactor
$500 ~ $999
_____ Sponsor
$250 ~ $499
_____ Patron
$150 ~ $249
_____ Household
$45
_____ Individual
$40
Note: Amounts over $30
are tax deductible |