Step 1 of 3 * Required Field
Payment Method: Pay by Credit/Debit Card
Pay by ECheck
Invoice Number:    Account number or others.
Amount: * This can also be a dropdown
  Credit Card Billing Information
First Name: *
Last Name: *
Street: *
City: *
State: *
Zip: *
Email: *
Phone: *    [xxx-xxx-xxxx]

(Max 255 chrs)

This can also be changed to additional fields you may require. They are then emailed to you in the Description response from

Please enter the Security Code:

                            Firefox Users
Upon submitting the form you will verify the information above.
You will then be directed to a Secure Page to enter your Payment details.
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