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Brehm Havel & Co LLP

Secure Payment Form

       
Date
Payment Amount
Client Number
Client Name
Invoice# (Optional)
Customer IP
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID (*Required)
Company Name
First Name
Last Name
Address
Address 2
City
State
Zip
Country
Phone Number
Email Address
Comments

Refund requests are reviewed individually by Management to determine refund eligibility. Valid refunds will be either credited to the customer's credit card account, or a check will be issued to the customer within two weeks of validation.