Alex Kenyon Payment Form

1
Customer ID
2
SEC Code
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Transaction Type
4
What are you paying for today?* This field is required.
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Facilitation fees
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What is the total payment amount?* This field is required.
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What account are we charging? * This field is required.Your security is our priority. We use secure e-checks with 256-bit encryption and TLS for complete data protection. Transactions are processed through an NCUA-accredited financial institution for maximum reliability and trust.
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Please Select
Checking
Savings
Account Type
First and Last Name of the Account Holder
Routing Number
Account Number
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How do we get in touch with you?* This field is required.
Email
Phone
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Signature* This field is required.By signing below you authorize the payment services provider for Alex Kenyon (TheraPay LLC), to initiate ACH debits from the bank account you have provided for services rendered and applicable fees. You also affirm that you have reviewed and approved the TheraPay Terms of Service available at therapay.org.
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Please verify that you are human* This field is required.
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