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Magcartapay

Account Number*
Repeat Account Number*
Full Name*
First Last
Email*
Cell Phone*
Address
Street Address Address Line 2 City State ZIP Code
Amount of Payment*
Settlement ?*
- Yes
- No
Payment in Full ?*
- Yes
- No
Type of card*
Credit Card Number*
Expiration date 01/18 month/year*
CVV number on back of card*
Please enter a number from 001 to 999.
Date to be deposited*