From: [ezine submission]  ([bill])
To: [tinker2@planetdeland.com]
Reply-to:[tinker2@planetdeland.com],  ([name])
Subject: [subject]


FirstName: [ ]
Address: [street]
City: [city]
State: [state]   Zip: [zip]
Phone: [phone]
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Item Reference:
[number]

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Payment Information:
[type]
[card]   [exp]

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Comments:
[comments]