Clone of Customer Payment Authorization Form

1
Full Name* This field is required.
First Name
Last Name
2
Company Name
3
Email Address* This field is required.
example@example.com
4
Use card on file* This field is required.
Yes
No
5
Last four digits* This field is required.
6
Front of Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
7
Back of Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
8
Keep this card on file for future payments?
YESNO
9
Amount to Pay* This field is required.
10
Invoices to pay/Remittance Information
Huge
Large
Normal
Small
Ok
Ok
11
3% Credit Card Surcharge
12
Total Payment (Including Fee)
13
Signature (Authorize Payment)* This field is required.
Should be Empty: