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This agreement shall be effective upon the date accepted by Accudata as evidenced by Accudata s receipt of an executed unmodified agreement. Signature Payment Type AmEx Visa Date MasterCard Discover Name on Card Billing Address State/Zip Cardholder Signature. By signing below Customer acknowledges and agrees to these conditions and authorizes Accudata to charge Customer s credit card for the services described above. 5333 NW 108th Ave. Sunrise Fl 33351 Tel 954 746-0399 Fax 954 746-0402 This...

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