Credit Card Payment

Name of Credit Card Holder(*)
Please enter the name of the credit card holder

Card Holder Email(*)
Please enter a valid email address for the card holder

Card Type(*)
Please select the type of credit card

Is this a new card to keep on file?
Invalid Input

Card Number(*)
Please insert the credit card number

Expiration Date(*)
Please enter date card expires

Verification Number or V-Code(*)
Please enter V-Code number

V-Code Locations

House Number & Street(*)
Please enter street number or P.O. Box number

City(*)
Please enter ZIP Code

State(*)
Please type in the City for the credit card billing address

ZIP Code(*)
Please provide the credit card billing address ZIP Code

Amount Paid $(*)
Please enter the amount to be paid (numbers only)

Name of Client Account Being Paid (whose account do we credit?)(*)
Please provide the name of the client who is to receive credit for this payment

Questions, Comments & Messages

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