PLG Date of Payment* MM slash DD slash YYYY NOTES/OTHER IMPORTANT INFOName* First Last Email* PhonePayment Amount*Please enter a number from 0 to 350.Payment Type*Money Order/Bank CheckPersonal CheckCheck Clear Date MM slash DD slash YYYY This field is hidden when viewing the form_add_to_blacklistset the default value of this field to "true" to add any new entries to the universal blacklistNameThis field is for validation purposes and should be left unchanged.
