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
January
February
March
April
May
June
July
August
September
October
November
December
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
*
Submit
Should be Empty: