PAYLEX™ for RFMS

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JESSIE J JAMES
8120 W 21ST Avenue
12345 -or- Y5Y6J6
(555) 555-1212
john.j.doe@xyzfloors.com
CG123456 -or- ES123456
Payment Amount
Pay-In-Full Selected
*Deposit-Only Not Selected
* Includes authorization to charge remaining balance at project completion.
PAYLEX Payments for FLOOR SOURCE ONLINE - PHOENIX, AZ
 
Card Number (Only!)
Expiration Month
Expiration Year
999 (3 -or- 4 digits)
0123412345
323070380
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