Personal Information
Account Number:  
First Name:  
Last Name:  
Billing Address
Address 1:  
Address 2:
Zip Code:    
Payment Amount
Payment Amount: ex. 2.99, 2.00    
Choose Payment Type:
Credit Card Accounts
Card Number:    
Card Code:    
Expiration Date:
eCheck (ACH) Accounts
Bank Name:  
Routing Number:    
Account Number:    
Account Type:
Terms and Conditions
I authorize the company named on this web form to debit the bank account or credit card indicated in this web form, for the noted amount on today’s date. This payment is for the goods and services noted on the web payment form. I understand that returns, refunds and cancellations are not permitted, however exceptions may be made on a case-by-case basis. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the company named on this web form may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card or bank account, and that I will not dispute the payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.