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Mail or Fax to: Laser Institute of America 13501 Ingenuity Dr., Suite 128 Orlando, FL 32826 Phone: 407.380.1553 Fax: 407.380.5588 For Office Use Only Date: Amt. Rev d ID # Please check here if you
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Method of payment one refers to the first payment method available for making a transaction.
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Information such as payment amount, recipient name and details, transaction date, and purpose of payment must be reported on method of payment one.
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