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PLC:

a004q7

Agency:

pascua yaqui tribe

For:

tribal gaming vendor license fees

Phone:

949-292-4738

Address:

7777 south camino huivism
tuscon, arizona 85757

*Required Field

Payment Information

*Vendor Name:

Middle:

*Last:

*Vendor Address:

*City:

*State:

*Zip:

*Vendor Phone #:

(### - ### - ####)

*License Fee Amount:

*License #:

Date:

(Month / Day / Year)

Payment Amount

Payment Type :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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