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Credit Card Info:
Visa or
MasterCard (Make
checks payable to: "GenoWare,
Inc.")
Number:____________________________________________
Exp._____________________
Name
as it appears on credit card:__________________________________________________
Ship
To Information: (Please print in large, bold letters
- Mail to address below.)
Name:_______________________________________________________________________
Address:____________________________________________________________________
City:_________________________________________
Country:______________________________________
State:____________________
Zip Code/Country Code_______________________
Phone
Number: _______________________________________________________
Email
Address: _______________________________________________________
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