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Secure Payment Form

Sponsor Purchase Summary:
Transaction Date: 07/21/18
[Insert Quantity in the Boxes Below & not "$" Amount.]
Platinum Sponsor - $500:
Gold Sponsor - $250:
Silver Sponsor - $100:
Bronze Sponsor - $50:
Total Charge $:
Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
[What is the Card ID?]
Purchaser Information:
First Name:
Last Name:
Phone Number:
Email Address:

Please Note: A record of this transaction will be emailed to you shortly, Thank-you!

I.A.P.A Santa Barbara , CA