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Payment Form

** - We participate in a discount program which offers our customers that choose to pay by Electronic Check/ACH an immediate discount on the 3.99% service charge, which is added to all sales

** - Admin Fee

3.99% will be added to ALL sales.

*** - Discount Program

We offer a discount to customers that choose to pay with electronic check.

Please fill-in the information requested below.  The fields marked with an asterisk ("*") are required fields.  Grayed out fields are read only!

Payer's Information

Please enter payer's first name.
Please enter payer's last name.
Please enter your company name.
Please enter payer's email address.
Please re-enter payer's email address.
Please enter payer's phone number.
Please enter payer's address line 1.
Please enter payer's zip code.

Reference Information

Please enter Payment Reference Information.
Please enter Additional Payment Reference Information.

Recurring


Recurring billing is a payment model that enables business owners to charge their customers at predefined intervals.
(NOTE: No payment will be charged today when a recurring payment is setup!)
Recurring payment start date is required.
Please specify the date you would like the first payment to be made.
Number of payments is required.
Please specify the total number of payments to be made, including today's payment.
Recurring payment end date is required.
Please specify the date you would like the last payment to be made.
Recurring payment end date is required.
Please check to indicate you authorize setup of payments on a recurring basis.
Recurring payment end date is required.
Please check to indicate your customer has authorized setup of payments on a recurring basis.

Payment Information

Please note: preset amounts fields have been locked per your merchant's request!

Please enter payment amount.
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Please enter payment amount.
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Please enter payment amount.
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Please enter bank routing number.
Please enter bank account number.
Please re-enter the bank's account number.
ACH Authorization Agreement

I certify that I am an authorized signer for the account indicated above and that I have the authority to authorize this transaction.  I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the date of this transaction.  I certify that the bank account specified is enabled for ACH transactions and agree to be responsible for all penalties and fees incurred because of my bank rejecting ACH debits or credits due to the account not being properly configured for ACH transactions.  Both parties agree to be bound by NACHA Operating Rules as they pertain to this transaction.  I acknowledge that the origination of ACH transactions to my account must comply with U.S. law.  I agree not to dispute this transaction with my bank provided the transaction corresponds to the terms indicated in this authorization form.

Thank you for your business!