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Nonprofit Name:
Amount Due:
First Name on Card:
Middle Name/Initial (if present):
Last Name on Card:
City:
King of Prussia
State:
PA
Zip Code:
Phone Number:
6107835627
E-mail Address:
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Credit Card Type:
Visa
Credit Card Number:
83566778564543
Expiration Date: (dd/mm/yyyy)
12/14/2002
Total Amount to be Charged:
$500.00
