Name exactly as shown as on Credit Card
Indicate type card (Visa or Mastercard only)
Credit Card Number
Street address or Box #
(where you receive bill for this card)

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Zip
Reserve your reservations to meet
Tom Tancredo
Saturday, November 1, 2003
PLACE: Gorgeous estate,
1823 Foothill Blvd, La Cañada, CA 91011
State
City
Email Address
(Enter "none" if no email address)
Daytime Phone Number
Amount to charge to card
$35 Single, $50 Double or Family
Expiration date MM/YYYY
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