General Payment Form

General Payment Form
568 NY-166 • Cooperstown, NY 13326 • Phone/Fax: 607-286-7322
Text 607-383-0772 • www.wahltowahlauto.com • sales@wtwap.net
Reference Number*
Acct, Quote, Inv, Verification or WO #(s)
Notes
Any additional notes or information
Billing Name*

First NameLast Name
Billing Company
Company Name
Billing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number
Fax Number
Mobile Number
Email Address
example@example.com
Preferred Method of Contact
Ship to Billing*
Shipping Contact Name

First NameLast Name
Shipping Company
Company Name
Shipping Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Shipping Contact Number
Total Due*

prevnext( X )
USD
Pay Later with no interest on qualifying purchases.*

*Terms & Conditions Apply. Choose the PayPal Pay Later option below to learn more.

Payment Methods

Debit or Credit Card

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