Web Payment Store Link

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Payment Method:

Credit Card

eCheck

Account Name:

JESSIE J JAMES

Billing Address:

8120 W 21ST Avenue

Billing ZIP/Postal:

12345 -or- Y5Y6J6

Phone Number:

(555) 555-1212

eMail Address:

john.j.doe@xyzfloors.com

Job Reference Num:

CG123456 -or- ES123456

Payment Amount:

Payment Amount

Payment Is:

Full Payment

Deposit

Card Number:

Card Number (Only!)

Exp Month:

Expiration Month

Exp Year:

Expiration Year

Security Code:

999 (3 -or- 4 digits)

Routing Number:

Federal Reserve Bank Match

Account Type:

Checking or Savings

Account Number:

Bank Account Number

Confirm Account:

Confirm Bank Account

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'Captcha' Text:

Confirm 'Captcha' Text

Confirm:

Press TAB after Confirm

Confirmed:

'Captcha' Confirmed?

Payment Method:

Credit Card

Name:

Address:

ZIP Code:

Phone Number:

Email:

Job Reference Num:

Full Payment:

Payment from: