CREDIT CARD PROCESSING FORM

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Dialer Account Number::
Amount Authorized: $:
Card number::
Expiration Month / Year::
Card Security Code:: *
Card Holder Name:
Billing Street Address Street 1:
Address Street 2:
City:
Card Holder Zip Code: (5 digits)
State:
Cell Phone:
Office Phone:
Email:
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you are the card holder
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