"First Name" field is required.

"Last Name" field is required.

"Street Address" field is required.

"City" field is required.

"ZIP Code" field is required.

"State" field is required.

"Country" field is required.

"Cardholder Name" field is required.

"Card Number" field is required.

"Expiration Date" field is required.

"Expiration Date" field is required.

"Security Code" field is required.

Billing
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Credit Card
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From
The Advantage Group
Advantage Group
43471 Ridge Park Drive, Suite B
Temecula, CA 92590
US
To
Jeffrey Nichols
1330 Neptune
Mexico, 65265
Date
December 18, 2019
Invoice Number
6326
Invoice Due
December 31, 2019
Invoice Total
$114.29
Balance
$114.29
  1. Task
    Rate
    Qty
    %
    Amount

    Direct Premium Billing November

    $110.96
    1
    -3%
    $114.29
Subtotal $114.29
Total $114.29
Balance $114.29

Notes

Thank you; we really appreciate your business.