Client ID (from invoice) *
Business Name *
First Name
Last Name
Address Line 1
Address Line 2
City
State
ZIP Code
Phone Number
Email Address (for confirmation)
Invoice #
Amount (USD) *
Payment DateOctober 27 - TodayOctober 28 - TuesdayOctober 29 - WednesdayOctober 30 - ThursdayOctober 31 - FridayNovember 1 - SaturdayNovember 2 - SundayNovember 3 - MondayNovember 4 - TuesdayNovember 5 - Wednesday
Payment FrequencyOne TimeOnce Every WeekOnce Every MonthOnce Every 3 Months (Quarterly)Once Every Year
Memo
* I understand that a 2.75% processing fee will be added to my total.
