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| Located in the top left corner of remittance stub. | |
| Invoice No.: | |
| Located in the top left corner of remittance stub. | |
| Company Name: | |
| Contact Name: | |
| Phone: | |
| E-Mail: | |
| Credit Card Information | |
| Your credit card information will be transmitted to LSBA via a secure internet connection. | |
| Billing First Name: | |
| Billing Last Name: | |
| Billing Address 1: | |
| Billing Address 2: | |
| Billing City: | |
| Billing State: | |
| Billing Zip Code: | |
| Billing Day Phone: | |
| Credit Card Type: | |
| Credit Card Number: | |
| Credit Card Expiration: | |
| Credit Card Security Code: | |
| Membership Dues $100.00 Annually Dues to LSBA are not deductible as charitable contributions for federal income tax purposes. Dues may be deductible as an ordinary business expense. |
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