Credit Card Payment Information Submission Form

This can be used by the Salesperson and/ or the Customer to establish limited vision and access to credit card information.




This is the email that you would like your receipt for processing to be delivered.




Please do not enter any dashes or spaces. Enter numbers only.


This is the address where the customer receives their bill for this card. It may not be the address of the property. It may be a PO Box as well.


This is the 3 digit code from the back of the card if Visa or MasterCard. The 4 digits from the front of the card if an Amex.


This is the Zip Code of the Billing Address of the card being used.


Please enter in MMYY format. No special character.




You are authorizing this amount to be processed on your card for this one time only.



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