Payment Authorization

Amount of your payment*

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Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Relation to couple
EX: Bride, or Mother of the bride etc.
Legal Signature of card holder:*
Legal signature of card holder:

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