Membership Payment Slip

Membership Level: [php] echo $_GET[‘level’]; [/php]

Name:

Address:

Address Line 2:

City:
State:
Postal Code:

Phone:

Email:

Payment Plan:

One-Time Payment of $[php] echo $_GET[‘one-time’]; [/php]
Monthly Installments of $[php] echo $_GET[‘monthly’]; [/php] for 12 months

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