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If you're ready with your credit
card information, we're ready to proceed.
Credit Card: Please check off which
card you're using. :
Name as it appears on Card
: *
Credit Card Number : *
Expiry Date on Card :*
Month
Year
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Client Consent
I
First Middle Last
Name Initial Name
hereby confirm that the information as provided is complete,
accurate and correctly reflects "Services" required. I have read,
understand and/or agree with the
Terms of Service Agreement
and Cityfax Privacy
Policy.
I do authorize the above order and the Cityfax charges to be
processed on the credit card, as provided.
Further, by pressing "Submit" button I/we consent to the
collection, use and disclosure of information; provided to Cityfax,
for the sole purposes of completing "Services Requested". This
could involve disclosure to various Federal/Provincial authorities,
responsible for administering programs and/or data files.
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