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| MASTERCARD / VISA DRAFT AUTHORIZATION | ||
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I, ___________________________________(CARDHOLDER NAME) authorize Pinellas County PBA to
debit my Visa/Master Card for my monthly PBA dues and/or dental premiums. Name (as is appears on the card) _______________________________. Card # __________________________ Master card or Visa (circle one). Expiration Date___________________. The amount to be debited from my account monthly is _____________. |
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