Payment Receipt 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. Description of items purchased:

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* 7. Itemized cost:

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* 8. Total cost:

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* 9. Payment method:

PayPal

Debit or credit card

Cash

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* 10. Amount paid: