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Secured Credit Card Payment Form

Generated with MOOJ Proforms Version 1.5

By filling out this form you authorize GENUINE WEB to use the credit card listed below in order to perform transactions when necessary. A receipt will be emailed to you each time there is a transaction.

*Required information.
Name *
Company Name *
Phone *
Email Address *
Billing Address *
City *
State *
Zip Code *
Name On Card *
Card Type *
Card Number *
Exp. Date *
Security Code *

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