George Lauterer Corporation
Secure Payment Form

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Order Summary:
Payment Date: 12/21/24
Payment Amount: *
Order/Invoice #:
Customer IP: 52.14.75.161 
Payment from Company/ Name: *
Phone Number:
Email Address:
Description:
           
Credit Card Information:
Card Type:

Name as on Card: *
Card Billing Address:
Card Billing Zipcode: *
Card Number: *
Card Expiration Date: MMYY *
Card ID (CVV2/CID) Number:
 [What is the Card ID?]		 *