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I authorize Live Holistic to debit the account listed hereon $69.00, & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Live Holistic Terms as referenced in the [Terms of Use] link below.

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Live Holistic
446 Bayridge Parkway Brooklyn, NY 11209
(718) 921-5483

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