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By clicking the submit button below I authorize the credit card transaction indicated on this form, for a one time charge of on . This payment is for goods and/or services detailed in the original receipt I received at the time I made my in store purchase. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this web form.

I understand that returns, refunds, cancellations, deliveries, and privacy are covered by the terms and conditions agreement.