Valor Intelligent Processing, LLC.

Transaction Summary

Today's Date:

04/24/24

Payment Amount:

Valor Reference Number:

Debit or Credit Card Information:

Card Type:

Name on Card:

Card Billing Address:

Card Billing Zip Code:

Card Number:

Card Expiration Date:

MMYY

Card ID (CVV2/CID) Number:

[What is the Card ID?]

Billing Information:

If billing info is different than card address/zip, please complete the section below.

Same as Billing:

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Phone Number:

Email Address:

If you would like to receive an receipt by email, please fill in the field.

If this transaction includes payment for multiple accounts, by clicking the "Process Payment" button, you are hereby authorizing Valor Intelligent Processing, LLC. to move any additional monies from this transaction to any other accounts owed by the account-holder.