| Payment Authorization to Contact USA Inc. |
| Your payment will be processed on the date indicated below - (you may change this date forward) |
| Required Fields: → |
∗ = required fields |
| Choose Payment Date (MM/DD/YY)∗ |
∗ |
| Payment Amount (example: 99.00)∗ DO NOT enter the "$" sign |
∗ |
| Full Name (John A. Smith, Sr.)∗ |
∗
↑ (actual client's name on an existing cerulean8.weebly.com account or name for an account to be created) |
| Daytime Telephone Number (212-123-4567)∗ |
∗ |
| E-mail Address∗ |
∗ |
| Would you like to charge all future payments to this account?∗ |
∗
|
| Full Name the way it appears on the Check or Credit/Debit Card∗ |
∗ |
| Type of Payment∗ |
∗
|
| Cient Number (enter only if known) |
↑ (enter only if known) |
| CHECK PAYMENT: the following fields (marked with red asterisk) are required ONLY if you selected to pay by check |
| Bank Name∗ |
∗ |
| Bank 9 digit Routing Number∗ |
∗ |
| Checking Account Number∗ |
∗ |
|
↑ The above must be a Checking Account Number (U.S. accounts only) |
| Check Number (optional) |
|
CREDIT/DEBIT CARD PAYMENT: the following fields (marked with red asterisk) are required ONLY if you selected to pay by credit/debit card
The payment will be listed on your statement as: CONTACT USA |
| Credit/Debit Card Number (no spaces or dashes)∗ |
∗ |
|
| Exp. Date (MM/YY)∗ |
∗ |
| Credit/Debit Card Security Code: (3 or 4 digits) (?)∗ |
∗ |
| Credit/Debit Card Billing Address∗ |
∗ |
| Notes, special instructions or anything else you wish to tell us |
|
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