Payment Form

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* 1. Name:

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* 2. Email:

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* 3. Phone:

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* 4. Shipping address:

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* 5. Billing address (if different from above):

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* 6. Items purchased:

Item A ($$)

Item B ($$)

Item C ($$)

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* 7. Shipping options:

Shipping option A ($$)

Shipping option B ($$)

Shipping option C ($$)

For help setting up payments through SurveyMonkey, please visit https://help.surveymonkey.com/en/surveymonkey/create/accepting-payments/