1. Enter Billing Contact Name* Title* Phone* (no spaces or punctuation: 5415551234) Email* 2. Enter Billing Address Street* City* State* —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Zip Code* 3. Choose Payment Type One Time Payment (No Fee on ACH/eCheck, 4% Fee on Credit Cards) Recurring Payment (No Fee) 4. Enter Payment Info ACH/eCheck Choose either one time or recurring payment in Step 3 above to view this form This form is used for Automated Clearing House (ACH) payments to provide payment-related information to your financial institution. By submitting this form you agree to the stipulations in the Authorization Agreement for Automated Clearing House Transactions. You must check with your financial institution to confirm that funds have been withdrawn. Transactions are negotiable for only 90 days. You can also download the form and mail it in to our office. Company Name* (As it appears on your bank account) Bank Name* Routing Number* Account Number* Account Type* Business CheckingBusiness SavingsPersonal CheckingPersonal Savings Payer/Authorized Official* Payer Title* Invoice Number(s)* Payment Amount: By completing this form, I agree to the ACH Agreement Terms and Conditions as presented by Phoenix Business Solutions, LLC. I certify that I am an authorized signor on this Depository Account. ACH Agreement Terms and Conditions This site is protected by reCAPTCHA and the Google.Privacy Policy and Terms of Service apply. This form is used for Automated Clearing House (ACH) payments to provide payment-related information to your financial institution. By submitting this form you agree to the stipulations in the Authorization Agreement for Automated Clearing House Transactions. You must check with your financial institution to confirm that funds have been withdrawn. Transactions are negotiable for only 90 days. You can also download the form and mail it in to our office. Company Name* (As it appears on your bank account) Bank Name* Routing Number* Account Number* Account Type* Business CheckingBusiness SavingsPersonal CheckingPersonal Savings Payer/Authorized Official* Payer Title* By completing this form, I agree to the ACH Agreement Terms and Conditions as presented by Phoenix Business Solutions, LLC. I certify that I am an authorized signor on this Depository Account. ACH Agreement Terms and Conditions This site is protected by reCAPTCHA and the Google.Privacy Policy and Terms of Service apply. Credit Card Choose either one time or recurring payment in Step 3 above to view this form Company Name* Notes Name on Credit Card* Card Number* Expiration MM/YY* CVV* (back of card) By submitting this form, I authorize Phoenix Business Solutions, LCC to charge my credit card above for agreed upon purchases on the day invoices are due. I understand that my information will be saved to file for future transactions on my account. This site is protected by reCAPTCHA and the Google.Privacy Policy and Terms of Service apply. Choose an amount Payment Amount (a 4% convenience fee will be automatically added) Company Name Invoice Number(s) (optional) Payment Amount (a 4% convenience fee will be automatically added) $ Notes (optional) Continue
