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First Name:

Last Name:

Company Name:

Address:

City:

Country:

Province:

Postal Code:

Enter as L6H3H3 (no spaces)

Email Address:

Where confirmation email from Paypal will go.

Payee Email Address:

For reference

Work phone:

Amount ($CAD):

Description:

Enter service or goods purchased.

Additional Notes:

Payment Status:

Pending

Paid by Cash

PayPal payment Verified

ProcessingDate: