Clients who prefer to make payments using a current credit card, please supply us with the information requested below. Setup payment will not be processed until our analysis of your situation is complete.

CARDHOLDER INFORMATION

First Name *

Last Name *

Billing Street Address

City

State

Zip *

CARD INFORMATION AND AUTHORIZATION

Card Type *

Credit Card #: *

Exp Date * 🛈

CVV * 🛈

Authorization Type: *

One-Time (enrollment (review and analysis) or other one-time charge)

Monthly (program fees for implementation or other recurring)

BOTH One-Time and Monthly

Enrollment / One-Time Charge Amount: $ 🛈

Monthly / Recurring Amount: $ 🛈

Quote given to me by: *

I authorize the processing center to charge the card listed above the agreed upon amount plus 3.5% processing fee. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement and the services arrangement with the processing center or representatives thereof. Providing the information in this form and submitting the form will immediately authorize the processing center to charge the card for the amounts and/or items listed.

I certify that I agree with the above statements and hereby submit this form. I will not dispute charges for the agreed-upon services and processing fee(s).

Certification: *

Yes