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Heart Crop Registration

February 11th ~ $5 *
First Name *
Last Name *
Email Address *
Phone Number *
Please charge my credit card you have on file *
Please use the following card *
Name on the Credit Card
Credit Card Number
Expiration Date
Three Digit Security Code
I choose to call with my credit card number I am aware that I have 24 hours. IF YOU ANSWER YES TO THE QUESTION USE MY CREDIT CARD ON FILE THEN PLEASE ANSWER NO HERE ** IF YOU ANSWER NO TO THIS QUESTION AND NO TO USING YOUR CREDIT CARD ON FILE YOUR REGISTRATION WILL BE THROWN AWAY AND YOU WILL HAVE TO RE-REGISTER. Your name cannot be put on the list for the crop until payment has been made and payment must be made within 24 hours or your registration is discarded. *
I am aware that all registration forms are non refundable. *