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GENESIS WATERS

Secure Payment Form

   
Date
Do you wish to make a recurring donation?
Do you consent to us securely storing your billing info?
Donation Amount
Frequency of Donations
Total number of Recurring Donations

Enter the total number of donations you would like to make. For example: 12 monthly donations just enter 12.

Start Date of Donations
Send Recurring Billing Receipt
First Name
Last Name
Address
City
State

Enter state as two letter ID, for example Michigan = MI

Zip
Phone Number

Do not include any special characters, just nine digit number including area code

Email Address
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 Check
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date

Enter date in format MM/YY

CVV2/CID

Enter three digit security code