QBME_Payment Form

Legal Name of Organization

DBA Name (if applicable):

EIN Number:

e.g., 23

Current Mailing Address of Organization

Street Address

Street Address Line 2

CityState

Zip Code

Who we can thank for referring you to us:

Please select the option in which you would like for your payment to be processed: (Please be aware that credit card payments will be assessed a 3% processing fee)

Bank Name

Name(s) on Bank Account (business name if used)

Account Number

must be 9-12 numbers - no spaces

Routing Number

must be 9 numbers - no spaces

Type of Bank Account

Bank Phone Number

Format: (000) 000-0000.

Date

Amount to be transferred:

(If not agreed upon in other communications)

First Name* Last Name* Date*
(Please enter the Client Name or Client Representative in the fields above)

Signature

Payment Amount

USDDescription

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Payment Options

Payment Amount

Payment Methods