Czech Ladies

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Your full name:

The name on the card:
 (only if different from above)
Credit card number:
Card ID (CVV2/CVC2)
There is no CVV2 code on the card
Credit card expiration date:
Credit card billing address:
(the address where you receive this credit card's statements)
Your telephone number:
Is this number: home work cellular
Alternative telephone number (optional):
Is this number: home work cellular
Your email address (optional):
Your order number:
(if you don't have your order number, make sure your name and email address are on this form)
Amount:
(Optional. If you know the amount of the charge)
Comments:
Your notes or comments about this payment (i.e. what is it for)
 

 

  By signing this form I authorize the company "" to debit my credit card the amount of US dollars for the above order.
  The prices for credits are the following:
12 credits - $20
60 credits - $60
105 credits - $100
320 credits - $300
550 credits - $500
 

 



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