| Please fill out the following form. Your billing address is used to validate your Credit Card and should match the address on your Credit Card. |
| Billing Information |
| If you have a foreign address (Outside the USA), please use box below. |
| * First Name: |
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| * Last Name: |
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| * Phone: |
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| * Email Address: |
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| * Address 1: |
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| Address 2: |
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| * City: |
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| State (if in USA): |
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| * Zip Code / Postal Code: |
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| Foreign Address Information: |
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| * Country: |
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Shipping Information
Same as Billing Information
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| If you have a foreign address (Outside the USA), please use box below. |
| * First Name: |
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| * Last Name: |
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| * Phone: |
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| * Address 1: |
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| Address 2: |
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| * City: |
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| State (if in USA): |
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| * Zip Code / Postal Code: |
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| Foreign Address Information: |
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| * Country: |
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| * Credit Card: |
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| * Name on Credit Card: |
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| * Card Number: |
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| * Expiration Date: |
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| Credit Card Verification Number: |
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VISA/MASTER CARD Verification # is a three digit number found in
the signature area on the back of your VISA/MASTER credit card. This
three digit number is displayed after your credit card number.
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| Comments: |
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Copyright © 2000 - 2010 Dakota Matrix Minerals
All photos by Dakota Matrix and are Copyrighted © and may not be used without permission
Last modified: March 10, 2010 |
