Step 2: Provide Payment Information
The dealer has indicated that you are using a purchase order. If the amount of the purchase order is
not for the full cost of the order or you would like to make a separate payment please do so by
indicating your payment preference below.
If not, please click "Minimum Met - Skip Payment" and then upload the purchase order if you have not
already provided it.
Autofill Name and Address from Order
Make
Payment via
Credit Card/Debit Card
Make
Payment via ACH
•••• •••• •••• ••••
FULL NAME
MM/YY
CVC: •••
Card Number:
Expiration Date (MMYY):
CVV2:
Billing Name:
Billing Address:
| City: | State/Province: |
Transaction Amount
Enter numbers only with a decimal if adding cents. Do not use dollar sign ($) or comma (,).
[Example: $1,002.50 would be entered 1002.50]
Please complete the fields below. After you have entered the required information and agreed to the acknowledgment below, you will need to click "Proceed with ACH Payment" to review the authorization form.
Bank Name
Check No. ••••
Pay to the order of First Last
$___________
•••••••••
••••••••••
••••
Last Name on Account:
Email:
Phone:
Bank Name:
Account Number  :
|
Confirm Account Number: |
|
Bank Routing # :
|
Confirm Bank Routing #: |
:
Bank City, State:
Transaction Amount:
Account Type:
By Clicking this box, you authorize to use information from your check to initiate a one-time funds transfer or process the payment as a check transaction.
Date:
CREDIT CARD SALE
CARD NUMBER:
TRAN AMOUNT: $
CASH DISC. ADD BACK: $
CARD TYPE:
ORDER NUMBER:
APPROVAL CD:
X
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{CARDHOLDER'S SIGNATURE}
I AGREE TO PAY THE ABOVE TOTAL AMOUNT
ACCORDING TO THE
CARD ISSUER AGREEMENT
One Time ACH Payment Authorization Form
Sign and complete this form to authorize to make a one time debit to your checking or savings account.
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This permission is for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.
I,
(full name)
to charge my bank account indicated below for
$
on or after
(amount) (date)
and reference
#
(check #)
Account Type:
Checking
Savings
| Name on Account: | |
| Bank Name: | |
| Account Number: | |
| Bank Routing #: | |
| Bank City, State: |
X
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ACCOUNT HOLDER'S SIGNATURE
I UNDERSTAND THAT BECAUSE THIS IS AN ELECTRONIC TRANSACTION, THESE FUNDS MAY BE WITHDRAWN FROM
MY
ACCOUNT AS SOON AS
THE ABOVE NOTED TRANSACTION DATE. IN THE CASE OF THE PAYMENT BEING REJECTED FOR NON SUFFICIENT
FUNDS
(NSF) I UNDERSTAND
THAT MAY AT ITS DISCRETION ATTEMPT TO
PROCESS
THE CHARGE AGAIN WITHIN 30 DAYS, AND I AGREE TO
AN ADDITIONAL $20.00 CHARGE (OR THE MAXIMUM AUTHORIZED BY STATE LAW) FOR EACH ATTEMPT RETURNED
NSF,
WHICH WILL BE INITIATED AS
A SEPARATE TRANSACTION FROM THE AUTHORIZED PAYMENT. I ACKNOWLEDGE THAT THE ORIGINATION OF ACH
TRANSACTIONS TO MY ACCOUNT MUST
COMPLY WITH THE PROVISIONS OF U.S. LAW. I WILL NOT DISPUTE BILLING
WITH MY BANK SO LONG AS THE TRANSACTION
CORRESPONDS TO THE TERMS INDICATED IN THIS AGREEMENT.
I (WE) UNDERSTAND THAT THIS AUTHORIZATION WILL REMAIN IN FULL FORCE AND EFFECT UNTIL I (WE) NOTIFY OR DEALER IN WRITING, BY PHONE OR DEALER LOCATION, THAT I (WE) WISH TO REVOKE THIS AUTHORIZATION. I (WE) UNDERSTAND THAT REQUIRES AT LEAST 5 DAYS.
I (WE) UNDERSTAND THAT THIS AUTHORIZATION WILL REMAIN IN FULL FORCE AND EFFECT UNTIL I (WE) NOTIFY OR DEALER IN WRITING, BY PHONE OR DEALER LOCATION, THAT I (WE) WISH TO REVOKE THIS AUTHORIZATION. I (WE) UNDERSTAND THAT REQUIRES AT LEAST 5 DAYS.
Order No: