U.S. Waiver Application Payment

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Client First Name

Client Last Name *

Client Email *

Client Date of Birth *

Card Type *

Name of Card Holder: *

Address *

Address

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City

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Card Number *

Exp. Month *

Exp. Year *

CVV *

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US Waiver Application *

U.S. WAIVER - Please use my credit card to cover the U$1100 U.S. Waiver Submission Fee

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