Secure Payment Form

Payment Summary:
Payment Date: 11/28/21
Account # (1 letter followed by 3 numbers):
Invoice Number:
This is a one time payment:
Pay this amount now and enroll me in auto-payments:
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Receipt via eMail:
Credit Card Information:     
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Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: Without slash. Example: May 2010 type: 0510
Card ID (CVV2/CID) Number:
[What is the Card ID?]

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Aprotex Corporation, 1011 W. Washington Ave.,
Midland, Tx, 79701-6667, (432)570-0188

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