Your InformationYour Company NameYour First Name*Your Last Name*Address*City*State/Province*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific---------------------Alberta, CanadaBritish Columbia, CanadaManitoba, CanadaNew Brunswick, CanadaNewfoundland and Labrador, CanadaNorthwest Territories, CanadaNova Scotia, CanadaNunavut, CanadaOntario, CanadaPrince Edward Island, CanadaQuebec, CanadaSaskatchewan, CanadaYukon, CanadaZip*Daytime Phone*Evening PhoneFax NumberEmail Address* File Number*Please Choose A Method Of Payment Below:Credit Card Payments are subject to a 4% processing feePayment Method*Electronic CheckCredit/Debit CardBitcoinElectronic CheckProvide the following Checking informationBank Name*Name on Check*Routing Number*Account Number*Account Type*Personal AccountBusiness AccountHow much will you be paying today?* (Use Numbers and Decimal Only)Authorization for Electronic Funds Transfer(*Required) By signing below, you authorize Accounts Receivable to make debit entries in the form of ACH transfers in accordance with the Payment Schedule. You acknowledge that the origination of ACH transactions to your account must comply with the provisions of U.S. Law and the Rules of the National Automated Clearing House Association. Your payment will be made automatically from your designated account. If your due date falls on a weekend or holiday, your payment will be deducted on the first business day following your payment due date. If there are insufficient funds in your account, Accounts Receivable may elect to electronically (or by paper draft) re-present your payment up to two more times. You also understand and authorize Accounts Receivable to collect a return processing charge by the same means, in an amount not to exceed that as permitted by state law. You may cancel this authorization by sending written notice to Accounts Receivable at the address above or at 877-832-2482, or by completing a new copy of this form. Accounts Receivable must be notified of revoked authorization at least 1 day prior to the payment due. *This authorization is valid for this transaction only. The transaction amount will be for exactly This authorization is valid for recurring debits to my account by use of check draft.Choose a Recurring Payment Cycle:*MonthlyDailyWeeklyYour checking account will be charged: $0.00 Please keep a copy of this authorization for your records. If you should have any questions concerning your payment arrangement please contact us at the phone number listed list above. *Authorized Card holder Electronic Signature** MM DD YYYY Date*Credit/Debit CardHow much will you be paying today?*(Use Numbers and Decimal Only Example: 3.23)CalculationTotal amount you will be charged* Price: $0.00 * By Checking this box I understand that there will be a 4% processing fee added to my payment. I understand that the total amount charged to my card/account will be BitcoinHow much will you be paying today?*(Use Numbers and Decimal Only Example: 3.23) This iframe contains the logic required to handle Ajax powered Gravity Forms.