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Tax Deductible contribution to The Politician: A Toy, Inc.

Please provide the following contact information: Fields marked by * are required
    Name: *

    Street Address:; *
    Street Address (2):; *
    City:; *
    State:; *
    Zip: *
    Country:;*
    Daytime Telephone: *
    Fax: *
    E-mail address: *

    Payment

You must fill in your credit card information completely to process this form!

I hereby authorize The Politician: A toy, Inc to charge my credit card in the
amount designated below. NOTE: You must fill out credit card information below. ALL SALES/CONTRIBUTIONS ARE FINAL

Credit cards accepted:


Credit Card: *
Cardholder Name: *
Card Number: *
Expiration Date: (Example: 12/05/99)*
Billing Address: *
Billing City: *
Billing State/Province: *
Billing Country: *
Billing Zipcode: *
Billing Telephone Number: *
Amount of Contribution: *

Remember, information will only be accepted if all required fields, marked by "*" are filled in completely

   

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