Please feel free to print this form, fill it out, and to include it with the money order you send to us. If you are unable to print it out for any reason then please note that you can send us this same info on any sheet of paper. We do require this information and the signature prevents fraud.

Name: _________________________________________________________ Date of Birth: _____________________ Street Address: _______________________________________________ City:____________________ State _______ Last 4 digits of your social to be used as a pin # _________________ Amount of Money Order: __________________ Signature Declarying you are of Legal Age: _______________________________________________________________

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