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Please charge my VISA MasterCard Discover or American Express Card circle one Exp. Date - Cardholder Name Billing Address NOTE Charge will appear on your credit card statement from Affinity Solutions Inc. Cardholder Authorization INDICATES A REQUIRED FIELD Revised 5. 00. Summary Letters 50. 00. Closed Cases Compliance Statements 50. 00. Summary Letters 250. 00. AMOUNT RUSH 10. RELEASE OF INFORMATION FORM 777 East Park Drive P. O. Box 8820 Harrisburg PA 17105-8820 Telephone 717 558-7819...
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