GENESIS WATERS
Secure Payment Form
Recurring donation Information
Date
Do you wish to make a recurring donation?
Yes
No
Do you consent to us securely storing your billing info?
Yes
No
Donation Amount
Frequency of Donations
Disabled
Daily
Weekly
Biweekly
Monthly
Bimonthly
Quarterly
Biannually
Annually
Total number of Recurring Donations
<p>Enter the total number of donations you would like to make. For example: 12 monthly donations just enter 12.</p>
Start Date of Donations
Send Recurring Billing Receipt
Yes
No
Designation (if any)
<p>Enter the specific purpose of this donation if designated (eg. Missionary Support, Mission Trip, etc.)</p>
Billing Information
First Name
Last Name
Address
City
State
<p>Enter state as two letter ID, for example Michigan = MI</p>
Zip
Phone Number
<p>Do not include any special characters, just nine digit number including area code</p>
Email Address
Pay By Check
If paying by bank account, please complete this section and click the box in "Pay by Credit Card" blue box that says pay by check.
Pay By Credit Card
Name as on Check
Bank Routing Number
Bank Account Number
Pay by Credit Card
Pay By Check
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
<p>Enter date in format MM/YY</p>
CVV2/CID
<p>Enter three digit security code</p>
Submit
