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* 1. Today's Day

Date

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* 2. Event Name

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* 3. Dates for visit

Date
Date

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* 4. Card Type

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* 5. Name that appears on Credit Card

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* 6. Credit Card Billing Address

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* 7. Card Number

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* 8. Expiration Date

Date

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* 9. CVV

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* 10. Driver's License State & License Number

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* 11. Home Address

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* 12. Club Affiliation

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* 13. I agree to allow Southern Yacht Club to charge the credit card I provided here for products and services I receive from Southern Yacht Club during the event or dates above. (Please Print Name as signature)

0 of 13 answered
 

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