Payment Auth Form – SpiritLife Inc.

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SpiritLife Inc.

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Cardholder Name *

First

Last

Email *

Phone Number *

Debit/Credit Card Number *

No spaces or dashes.

Amount Zip Cardholder

Expiration | CVC | Billing Zip Code *

First

Middle

Last

Enter Amount to Authorize *

Minimum Price: $10.00

Payment Confirmation *

I hereby authorize SpiritLife Inc. to charge my credit card with the amount above.