GB Collects
Secure Payment Form

echeck
 
Order Summary:
Date: 06/12/21
Amount: *
File #: *
Customer IP: 3.215.79.116 
Description:
           
Checking Account Information:
Account Holder Name: *
Bank Routing Number: *
Bank Account Number: *
Billing Information:
Company Name: *
First Name: *
Last Name: *
Address: *
Address Line 2:
City: *
State: *
Zip: *
Country: *
Phone Number: *
Email Address: *
     
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