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FMA shall charge Licensee whatever FMA determines to be a reasonable charge for those additional amenities. Cardholder Print Name Sign and Date Below Once signed return the completed form via Fax 612-573-0334 or mail do not send via email it s not secure D1 S10 S20 S30 S40 D2 S11 S21 S31 S41 D3 S12 S22 S32 S42 D4 S13 S23 S33 S43 D5 S14 S24 S34 S44 D6 S15 S25 S35 S45 D7 S16 S26 S36 S46 D8 S17 S27 S37 S47 D9 S18 S28 S38 S48 D10 S29 S39 S49 X3 X4 D11 D12 X1 10x11 X2 10x10 10x12 D13 D14 D15 P10...
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