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Credit Card Authorization Form
I authorize Accela ChemBio Inc. to process the following payment to complete orders below.
Billing Information
Company:  *
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CA Sales Tax, if any  *
Total Amount  *
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Credit Card Number: To eliminate number guessing(Print Only Pleas):  *
Expiration Date  * / Card Security Code  *
Cardholder's Name  * Cardholder's Signature * Date *
E-mail: (for receipt receiving if needed)
Accela ChemBio www.accelachem.com
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