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.
Project Name - Last Name, First Name - Type of Work
This is the email that you would like your receipt for processing to be delivered.
Name As It Appears on Card
Credit Card #
Please do not enter any dashes or spaces. Enter numbers only.
Street Address where card's billing is delivered
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.
SEC or VCode
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.
Billing Zip Code
This is the Zip Code of the Billing Address of the card being used.
Expiration Date on Card
Please enter in MMYY format. No special character.
Credit Card Type
Amount to be Charged
You are authorizing this amount to be processed on your card for this one time only.
Please check if this card is a Debit Card
If the card is a Debit Card you will most likely have to notify your bank of the exact amount to be processed prior to processing. Our Finance Department will call you if this becomes necessary.
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