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 DateFebruary 4 - TodayFebruary 5 - SundayFebruary 6 - MondayFebruary 7 - TuesdayFebruary 8 - WednesdayFebruary 9 - ThursdayFebruary 10 - FridayFebruary 11 - SaturdayFebruary 12 - SundayFebruary 13 - Monday
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.
