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A convenience fee of 2.50%(Credit Cards)or 1.50%(Debit Cards) of the payment amount will be charged. All business credit/debit cards are 2.50% of the payment amount and E-checks are a flat fee of $1.50, which is charged by Value Payment Systems for the use of this service.

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Expiration Year*
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CVV*

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Billing Information

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Cardholder First Name*

Last Name*

Billing Address Line 1*

Billing Address Line 2

City* Town/City *

State*
Select a State --Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe, Middle East, Africa, Canada Armed Forces Pacific

Zip Code*

Province/Region*

Postal Code*

Country*
Select a Country -- United States Minor Outlying Islands Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Bassas da India Belarus Belgium Belize Benin Dahomey Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Upper Volta Burma Burundi Cambodia Kampuchea Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos Keeling Islands Colombia Comoros Congo Brazzaville Congo Zaire Cook Islands Coral Sea Islands Territory Corsica Costa Rica Cote D'Ivoire Ivory Coast Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt  El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands Islas Malvinas Faroe Islands Fiji Finland France French Guiana French Polynesia Tahiti French Southern and Antarctic Lands Gabon Gambia Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary  Iceland India Indonesia Iran Iraq Ireland Eire Isle of Man Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnston Atoll Jordan Juan de Nova Island Kazakhstan Kenya Kingman Reef Kiribati Gilbert Islands Korea South Kuwait Kyrgyzstan Laos Latvia  Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Palmyra Atoll Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovakia Slovenia Solomon Islands Somalia South Korea South Africa South Georgia and the South Sandwich Islands Spain and the Canary Islands Spratly Islands Sri Lanka St. Helena St. Kitts St. Christopher and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard Spitsbergen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands British Virgin Islands US Wake Island Wallis and Futuna West Bank Western Sahara Western Samoa Yemen Aden Yugoslavia Zambia Zimbabwe

Check Type*
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Bank Routing Number*

Account Number*

Confirm Account Number*

Business Name*

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Billing Information

 Billing Information is the same as above.

Account Holder's First Name*

Account Holder's Last Name*

Account Holder's Address Line 1*

Account Holder's Address Line 2

City*

State*
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--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe, Middle East, Africa, Canada Armed Forces Pacific

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