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| FIDELIS BOOKKEEPING | |||||||||||||||||||||
| Name as it appears on card: | |||||||||||||||||||||
| Type of account: | |||||||||||||||||||||
| Credit card number: | |||||||||||||||||||||
| Account number: | |||||||||||||||||||||
| Routing numbuer: | |||||||||||||||||||||
| By clicking the sumbit button you are authorizing Fidelis to withdrawl from the indicated account, for the stated monetary amount. All funds will be process in U.S. currency. | |||||||||||||||||||||