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SSL
Payment: onlinecasinolime.com - SSL (Secure Sockets Layer) - Secure Payment Site.
Product/Service: qlWebDS-Premium
This is Contact USA's Secure Payment Site - processing payments for onlinecasinolime.com Contact USA, Inc.
- you may submit your payment online by filling out the following form and submitting it to us directly by clicking on the Submit button below
       -or-
- fill out the following form, print it and fax it to us to: 845-621-4449.
When paying by a credit/debit card, your payment will be listed on your statement as: CONTACT USA
.
Payment Authorization to Contact USA, Inc.
Your payment will post to your account 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 onlinecasinolime.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    
I hereby expressly authorize and instruct my financial institution to charge my account specified above and to deduct the amount specified above and remit directly to Contact USA, Inc. electronically, by paper means, or any other commercially accepted method. Furthermore, if I indicated above (Yes) that all my future payments are to be charged to the above mentioned account, Contact USA, Inc. will process such payments as soon as my account accrues any balance. When paying by a credit/debit card, my payment will be listed on my statement as Contact USA.
  
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