Gloucester County

Secure Payment Form

Payment Amount
Dog Name
This information is used in the case that a payment cannot be matched to a license and to email a receipt.
First Name & Last Name
Phone Number
Email Address
Name as on Check
Bank Routing Number
Bank Account Number
Drivers License Number
Drivers License State
I authorize Gloucester County to initiate a single ACH/electronic debit to my account in the amount entered above from the bank account entered above. I agree that ACH transactions I authorize comply with all applicable laws. Payments made after 8:30 P.M Eastern time will be applied as of the next business day. To complete the payment process, click the “Submit” button. Once payment is authorized, there cannot be any changes or corrections. It is recommended that you print a copy of this authorization and maintain it for your records.