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Miami Outreach Payment
Your current personal information
*E-Mail:
*First Name:
*Last Name:
*Address Line 1:
Address Line 2:
*City:
*State:
Zip Code:
Country if other than USA:
Phone:
 
I would like to pay by credit card
Card number:
Name as it appears on the card:
Expiration Month:
Expiration Year:
Three-digit security code (Found on back):
 
I would like to pay by electronic check from my bank account
Type of account:
Checking - personal
Checking - corporate
Savings - personal
Savings - corporate
Bank ABA/Routing number:
Bank account number:
Your name as it appears on bank account:
 
Amount of payment
Amount I wish to pay:
 
Comment or special instructions
If you would like to send us a comment or special instructions, do so here:
 
OAC Box D, Nazareth, PA 18064 usa@oaci.org oacgive.org (610) 746-0508
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