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PRINT this page and fill in the Authorization Form.
Sign it and either
Fax (808 875-1567) or mail it to us.
You may also call in your authorization,
800 981-5512. |
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| Date
__________ |
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Name ____________________________________________ |
| Address
__________________________________________ |
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City
_________________________ State ____ Zip _______ |
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VISA/MasterCard
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Express ____ |
Discover
Card ____ Diners Club ____ |
| Credit Card Number
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| Expiration
Date __ __ / __ __ |
| Signature
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