Make a Payment
Payment Summary
Company Name
Invoice No.
Payment Amount
Convenience Fee
0
Total Amount
$0.00
Card Number
Exp. Date
CVV
Name on Card
Billing Street Address
Postal Code
Email Receipt To:
By clicking Pay Now, I agree to pay [dba]
the above amount in accordance with the Card Issuer Agreement.
*
First Name
*
Last Name
Email Receipt To:
Account Type
Checking
Savings Account
Account Holder's Name
*
Routing Number
*
Confirm Routing Number
*
Account Number
*
Confirm Account Number
By clicking on “Pay Now,” I hereby authorize [dba] to initiate an electronic single debit entry from the above indicated bank account in the amount entered (or provided) on this page. I understand that if this transaction is submitted after 6:00 PM Eastern Standard Time, it will have an effective date of no sooner than the next business-banking day and will show as a withdrawal from my account on that date. If I wish to revoke this authorization, and revoke this payment, or the amount withdrawn from my account is different than the amount authorized herein, I may call [csn] during [dba] business hours which can be found by visiting their website: [website] . Furthermore, I assert that I am the owner or an authorized signer of the bank account provided
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