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Lightning Linebacker Fitness Response Form |
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FAX this form to 1- 419-754-2253
___ Enclosed is my check, money order or credit card order for $_____________.00
plus $14 S&H ($27 foreign orders)
Totaling $__________________.00
Charge my (Note - You can use more than one card to complete this order):
Visa, Mastercard, American Express
Card Number:_____________________________________________ Exp. Date:______________
Signature: __________________________________________
Print Name: _______________________________________________________________________
Address 1: _________________________________________________________________________
Address 2: _________________________________________________________________________
City: ______________________________________ State: __________________________________
Zip Code: ______________________________ Country: __________________________________
Date of Birth: _____________________________________
Telephone: _______________________________________________
Fax Number: _____________________________________________
E-Mail: __________________________________________________
Or Mail This Form To:
Vince Palko Enterprises, LLC
7051 Ramblehurst Dr.
Sylvania, OH 43560
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