LED Badge: Purchase with a Credit Card

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^* Name on Card

^* Card Number

^* CVV Please enter the CVV code (typically found on the back of the card).

^* Expiration Date

Contact Information

^* Email

^* Phone

Mailing Address

^* First Name

^* Last Name

^* Officer Title

^* Chapter Zeta Designation

Chapter (Zeta)

Associate Chapter (Colony)

^* Chapter or Associate Chapter Name

Address line 1

Address line 2

^* City

^* State

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^* ZIP Code

The mailing address is the same as the shipping address

Uncheck the checkbox if your shipping address is different.

Shipping Address

^* First Name

^* Last Name

^* Officer Title

^* Chapter Zeta Designation

Chapter (Zeta)

Associate Chapter (Colony)

^* Chapter or Associate Chapter Name

^* Address line 1

Address line 2

^* City

^* State

AL

AK

AZ

AR

CA

CO

CT

DE

FL

GA

HI

ID

IL

IN

IA

KS

KY

LA

ME

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

DC

^* ZIP Code

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