Credit Card Payment - SSL Secured

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.

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* 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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