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Mail Contribution

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MAIL CONTRIBUTION

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Fold here for windowed envelope
Please verify the information below one last time. The address must match your credit card billing address. If correct, simply complete the bottom portion of this form.
Moniker/Name:  
Billing Information:  
 
 
 
  ,  
 
Primary Day Phone #:  
Secondary Phone #:  
Fax Phone#:  
Credit Card Information:
Visa Mastercard Discover American Express Check Enclosed (Payable to Audio Asylum)
Exact Name on Card:  
Number:     e.g., 5412-1234-5678-9012
Expiration Date:   / e.g. 01/15
CVV Code:  
  e.g., 860, 3 digit number on back of card or
  8609, 4 digit number on front of card (Amex)
Amount:
(required, pick one)
  Undiagnosed $US 25.00
  Outpatient $US 50.00
  Inpatient $US 100.00 (Excellent choice!)
  Certifiable Loon $US 250.00
  Straight Jacket Club $US 500.00
  Frontal Lobotomy $US 1,000.00
  Fully Lobotomized $US 5,000.00
  Other
 If Other, please specify in $US  
Comments: