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I authorize Flex Endo to charge my account for on or after. This payment is for Purchase order number or product to be listed Billing Address Phone City State Zip Email Card Type Visa Mastercard Amex Discover Cardholder Name Card Number Experation Date CVV2 3 digit code 4 digit for Amex PLEASE NOTE 3 Convenience fee for all credit card sales SIGNATURE Date 6421 Inkster Rd STE 102 Bloomfield TWP MI 48301. Credit Card Payment Authorization Form Please complete this form and fax back. By...

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