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Steuben Center For Rehabilitation
7009 Rumsey Street Ext • Bath, NY 14810-7827
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
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Amount
*
+ Convenience fee: 3%
on
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Final Amount
Residents Name
*
Residents Phone
*
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Credit Card Details
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*
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By clicking this form, you give Steuben Center For Rehabilitation permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
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Steuben Center For Rehabilitation
7009 Rumsey Street Ext
Bath, NY 14810-7827
Tell: 607-776-7651
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
