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Purchase Merchandise

Amount

Fill in other amount if purchasing multiple items
$25.00 one hat or t-shirt
$6.00 ship merchandise

Other Amount

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Please type what merchandise are you purchasing? (Required)

Credit Card Information

Cardholder Name (Required)

Credit Card # (Required)

Visa MasterCard American Express Discover Diners Club

Expiration Date (Required)

Security Code (Required)

Visa®, MasterCard®, Discover® & Diners Club® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

If we are shipping the merchandise, please fill out the fields below.

Ship to name

First Name

Last Name

Ship to address

Country

Address Line 1

City

State/Province

Postal Code

We have two styles of T-shirts and two styles of hats to choose from.

Shirt One

Shirt Two

Baseball Hat (in black or pink)

Trucker Style Hat (in black)

Partner
Partner
Partner
Partner
Partner
Mix Bakery
Interwest Insurance Services LLC
Famous Footwear
Dutch Brothers
Ticket To Dream
PG&E
West America Bank
Elks Lodge 1240
itmercedcom
ActionComputers

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