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Apricot Lane Billings Order Form
Customer Information
First Name:*
Middle Initial:
Last Name:*
Address Line 1:*
Address Line 2:
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Phone:*
Birthday Month
E-Mail:*
Credit/Debit Card Information
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Expiration Month:*
Expiration Year:*
Card Brand:*
CVC*
Item
Pick Up in Billings, MT or Ship
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