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Terms & Conditions
Recurring Payment
*Terms:
One Time
Ongoing
12 months
24 months
36 months
Company
*First Name:
*Last Name:
*Company:
*Occupation:
*Address Line 1:
Address Line 2:
*City
*Country:
*State/Province:
*Zip/Postal
*Email Address:
Credit Card
Check
CardNumber
Expiration Date
Credit Card Security Value
Name on Bank Account
* Bank Routing Number
*Bank Account Number
By clicking Submit and authorizing this transaction, customer agrees that merchant may convert this transaction into an Electronic Funds Transfer (EFT) via ACH transaction and to debit this bank account for the amount specified. Additionally, in the event this EFT is returned unpaid, a service fee, as allowable by law, will be charged to this account via EFT or ACH. In the event you choose to revoke this authorization, please do so by contacting the merchant directly. Please note that processing times may not allow for revocation of this authorization.
Payment Date:
07/06/2022
*Payment Amount:
$
* indicates a required field
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