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| SuperCub.Org | |||||||||
| Membership Donation Fax/Mail Form | |||||||||
| Please Send Form To: | Straight and Level Productions, Inc. | ||||||||
| Post Office Box 150 | |||||||||
| Waldron, Mo 64092 | |||||||||
| Fax: 203-413-6360 | |||||||||
| Please Print: | Phone: 816-741-1486 | ||||||||
| Date: | |||||||||
| Name: | |||||||||
| Address: | |||||||||
| City: | |||||||||
| State: | |||||||||
| Zip: | |||||||||
| Phone: | |||||||||
| Email: | |||||||||
| SuperCub.Org Login Name: | |||||||||
| Donation Amount: | $ | (US Dollars) | |||||||
| Credit Card Information (you may also mail a check instead with this form) | |||||||||
| Card Type: | Visa____ | Mastercard ____ | |||||||
| Card Number: | |||||||||
| Name on Card: | |||||||||
| Security Code on Back of Card (3 digit number on the right): | |||||||||
| Expiration Date (mm/yy): | |||||||||
| I herby authorize Straight and Level Productions to Charge My Credit Card for the Above Donation Amount: | |||||||||
| Signature: | |||||||||
| Comments: | |||||||||
| THANKS FOR SUPPORTING SUPERCUB.ORG! | |||||||||