- Century Club Gift Remittance Form-

__ Check payable to APBA Historical Society 100th Anniversary

__ Visa | __ Mastercard | __ American Express | __ Discover

______________________________________________________________________
Card Number                                         Name on Card (Please Print)

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Expiration Date                                         Street Address

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Signature                                         City                      State             Zip

[ ] $200 Century Club                          [ ] 100th Anniversary
[ ] Other Projects _________________   [ ] Other Amounts _____________

Non Profit Tax Deductible IRS 501 C-3

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