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| A contribution of
$________________ |
| . |
| Method of Payment: |
| __ Check payable to Boys & Girls Clubs of
Huntington Valley |
| . |
| __ Charge my: ____ Visa
____ MC ____ AmEx |
|
Card
Num.: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
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|
Exp. Date: __ __ /__ __
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Cardholder: _____________________
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Signature: _____________________ |
| . |
| Name:
______________________________________________________ |
|
Address: ____________________________________________________ |
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City, State, Zip: _______________________________________________ |
| . |
|
Thank you for your
support! |
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|