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In paying here you agree with the following:

 
You are 18 years of age or older
You are authorized to use the following credit card account

 

Please continue by providing the following information.

Note: Items with a star* are necessary to process your request. All other fields are optional (though helpful), and either an e-mail address or phone number is required to contact you.

*First Name
*Last Name
*Address (Must match billing address)
City
State
*Zip
*E-Mail
*Credit Card Number Visa, MasterCard or Discover.
*Expiration Date (Billing will show as "COIN Services")
*CVV (Number on back of MC/VISA. See below.)

 *Amount to pay:  

Please give us your invoice number, or any comments:

Thank you for choosing COIN Services. We look forward to serving you!