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     Note : Extra charge 3% of your selected package category from your credit card.

     Date Register :    9/5/2010

     User Name :   

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     Last Name :   

     IC :   

     DOB :     
     (mm/dd/yyyy)

     Gender :    Male Female

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     City :   

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     Postcode :   

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     Email Address :   

     Credit Card Type :    Visa Mastercard American Express Discover

     Card Holder Name :   

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     CVV2/CVC2 :    Last 3 digits on the back of your card

     Expiration Date :    January February March April May June July August September October November December 2010 2011 2012 2013 2014

     Package Category :    25 50 100 200 500

     Sponsor & Placement ID : Yes No

     Sponsor ID :   

     Placement ID :       L R

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