Hosting / Website Payment Form

Customer E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address. This form is to securely collect your credit card info only. Your CC will be run manually for the price previously agreed to. Regards, Janet Julian 760-458-0555 Verle Yoder 775-781-3739
*E-Mail:
Billing Information
*First Name:						Same name as on your card
Middle Initial:
*Last Name:
*Address Line 1:						Where your statement is mailed
Address Line 2:						Apt. or Suite No.
*City:
*State:
*Zip Code:
Phone:
Credit/Debit Card Information
*Card Number:						No dashes or spaces please
*Expiration Month:						From your card
*Expiration Year:						From your card
*Card Brand:
*Card ID Number (3 Digit) not required for AMX						3 Digit Code on Card

Enter the security code shown above in UPPER CASE.
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