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center>Select Your Favorite Candy
First Name:
Last Name:
Address Line 1:
Address Line 2:
City: State: Zip Code:
E-mail Address:

Hershey bar
Snickers bar
Candy Corn
Chocolate kisses
M&M's
Twix
Baby Ruth

Standard Mail
Overnight
Same Day Delivery

Credit Card Number:
Expiration Date (mm/yyyy):






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