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Remittance Advice

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					                              Remittance Advice
FAX NUMBER: 04 463 5045

Attention Suzan Hall,

SURNAME: ________________________________________

FIRST NAME: ______________________________________

AMOUNT: _________________________________________

PAYMENT METHOD: Please tick the appropriate box

Master Card:                      Visa:

Credit Card Number (Master Card/Visa):

Expiry data:   /

Cardholder’s Name: _________________________________________

Cardholder’s Signature: ______________________________________

Receipt: ______________________________________
Please provide the details of the participants for the payment above:

Participant’s Full Name:                      Amount ($60/$120/$200)

				
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posted:10/15/2012
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