ICA New Students and Level Advancements
On-Line Payment Form

International Combat Association
P.O. Box 281
Grand Blanc,   MI   48480   USA

Complete the form below and then click "Submit Application" at the bottom of this page.

Please allow 4 to 6 weeks for processing.
(Payments are to be in U.S. Currency)

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Credit Card Holder Information
(All certificates will be sent to the following address)

Name (As it appears on Card):
Street Address:
Zip Code:
Phone: (Required
E-Mail Address (Required)

Credit Card Information

Card Number:
    Credit Card:     Exp. Date: Month       Year:

Total Fees For All Students

Number of New ICA Members:   x $35.00   =  
Number of Level Advancements:   x $30.00   =  
Total Fees:

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