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Your Name: _______________________________________________
Company: _______________________________________________ (optional)
Street Address: _______________________________________________

_______________________________________________
City or Town: _______________________
State or Region: _______________________
Phone Numbers:
Please include c area code
Daytime: ________________ Evening: ________________
Email address:
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Credit Card Details
Type of Card:
Check one of these options
[ ] VISA    [ ] MasterCard    [ ] AmericanExpress    [ ] NOVUS/Discover
Credit Card Number: ________________________________________
Expiration Date: Month: ____________ Year: ____________
Amount: $ ____________ . ___ U.S. Dollars  
Cardholder's Name: _______________________________________________
Cardholder's Signature:
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In order to avoid losing your info, If you have problems submitting your form, ( for example you get a message: "oops!  must be a tripod website" ) after you receive the oops message, just click the "back" button and complete the missing information - if you still receive an oops message,  you may want to just print the completed form and mail it to:  xkr essex, inc. 2911 e. vista st. #C long beach, ca 90803