St. Patrick Church

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Online Credit Card Payment

Qty

Description

Amount

Total

Registration Fee

$50.00

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OR PAY LATER

Qty

Description

Registration - Pay Later

Your Information

First Name: *

Last Name: *

Member ID:

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Home Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card:

Card Number:

Security Code:

Expiration Date: