Payment Form

SW Louisiana Association of Realtors

If you would like to pay online please fill out this form.
Date

Month Day Year
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
E-mail *
Apply amount to:
(Include invoice#, MLS month, MLS infraction#, ect. if applicable)
Apply to *

Invoice MLS Dues MLS Infraction New Member Dues
MLS Dues Month
MLS Dues Month
MLS Infraction #
Company/Brokerage *
Invoice #
If other please explain
GMM, Christmas Party, Ect.
Amout to pay *
This is before processing fee
How would you like to pay *

Credit card (under $200-$3 processing fee)(Over $200 3.4%+$0.25 processing fee) ACH/Bank Transfer(has a 1% fee upto max $10 processing fee
Total with processing fee
ACH/Bank Transfer
Account Type

Personal Business
Account Type

Checking Savings
E-Check #
Name on Account
Routing #
Account #
Credit Card
Card Holder Name
Billing Address
Billing City
Billing Zip Code
Credit Card #
CVV#
Expiration Date
Please verify that you are human *
Should be Empty:

SW Louisiana Association of Realtors