#  $10 -
 SAME # as your WRIST-BAND  -  COVER PAID reg-5555 - 121720  PW LAST 4 DIGIT PHONE #

*FIRST   *LAST *email:

ADDRESS  CITY  *ZIP
CREDIT INFO
*) = must fill out
*Credit Card  *Exp Date  *Code
*PayPal account @     plz NO PP passwords!