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Monthly Luncheon Credit Card Payment Form
June Luncheon
June 2, 2016
11:30AM
The Las Vegas Country Club
Event Attendance:
Members
Event Attendance:
NonMembers
Grand Total:
Personal Information
First Name:*
Last Name:*
Company*
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
E-Mail:*
Phone:*
Discount Code:
Additional Attendees:
Credit/Debit Card Information
Card Number:*No dashes or spaces please
Cardholder First Name:*
Cardholder Last Name:*
Expiration Month:*From your card
Expiration Year:*From your card
Card Brand:*
Billing Address:*
Billing City:*
Billing Zip Code:*
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