EXCEL-WEST PAYMENT CENTER


Please read the Professional Services Agreement

Your information will be sent over a secure connection.
 

Client Information (Section B). *Required Fields

 
*Client
* Authorizer's First Name
* Authorizer's Last Name
*Client Address 1
Address 2
*City
*State US states:
Other countries:
*Zip
*Country
Contact E-mail Address
Client Phone

Payment Info:
Check here to use same address info as above:

*First Name as it appears on the credit card

*Last Name as it appears on the credit card

*Address where credit card
statement is sent: Line 1

Line 2

*City

*State

US states:
Other countries:

*Zip

*Country

 
   

*Payment Information

*Card Number

*3 or 4 Digit Security Code

*Month
*Year
I authorize EXCEL-WEST to charge my credit card.
* Enter invoice or down payment
amount per email communication.
   
Invoice or Estimate Number
(if applicable)
Please enter any access information that may be required for this project if available such as website access information including host name, user ID and password. Thank you
 

By initialing here, * I acknowledge that I have read and understand the Professional Services Agreement Terms and Conditions and that I am executing this agreement by clicking "I Agree." I CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind Client to this Agreement.


Thank you for your business.

 

 

 

 

 

 

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