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Restricted-Use Contractual Data Online Payment

Please provide the following information in order to use a credit card to pay the non-refundable fee for the Add Health restricted-use data.

Amount:
Investigator Name:
Investigator Institution:
Investigator Email:
Investivator Phone:
Contact Person:
Name of the person to contact about the information provided on this form. Leave blank if same as Investigator.
Contact Email:
Contact Phone:

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Page Last Modified: 09/04/2007
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