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and Wagner House Wedding Centre
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Wedding Gown Preservation Kit Order Form
 
Bride's First Name:  
Bride's Last Name:   
Address:   
City:   
State:  
Zip Code:  
Telephone:  
Cellphone:  
Email:  
Wedding Date:  
Promotional Code:  

Payment Method:     
Credit Card #:   

Expiration: (mm/dd)     V Code:

I hereby authorize the above credit card to be billed in the amount of  $175.

Signature:    Date: 

 
     
     
Wagner House Wedding Centre