Easy Pay Consent Form (Page 3 of 3) in pdf

Easy Pay Consent Form Page 3

Credit Card Information (1

card)

Use for Payment date(s): ______________________________________________________________

 VISA

 MasterCard

 American Express

Card Type:

Card Number:

Security Code: ___________

Expiration date: __________________ Cardholder:

Cardholder Billing Address:

Apt/ Ste/PO Box_______

_________________________________________________________________________________

City:

State ________ Zip code ________________

Cardholder Contact Number (

)

Email: ____________________________

Credit Card Information (2

card)

Use for Payment date(s): ______________________________________________________________

 VISA

 MasterCard

 American Express

Card Type:

Card Number: _____________________________________________ Security Code: ___________

Expiration date: __________________ Cardholder: ______________________________________

Cardholder Billing Address: ______________________________________ Apt/ PO Box#________

_________________________________________________________________________________

City _______________________________________ State ________ Zip code _________________

Cardholder Contact Number (

)

Email: ____________________________

Please fax or scan/email the completed form to:

Accounting Department

Email:

Fax: 210.691.8972

Inquiries: 800-259-5562

Page 3 of 3

Easy Pay Consent Form Page 3