PGM Client Payment Center

To be completed by Client:

Type of Credit Card: Amount $: Account #:

Please keep this credit card on file for payment of all invoices.If an email is provided below, a receipt will be emailed as payments are processed.

Card Information

Card Number Expire Date

Card Code (3-digit number following the card # of the back of the card)

Card Holder Name

Company Name

Address

City State Zip Code

Telephone Fax

E-Mail Address (required for receipts)

CREDIT CARD TRANSACTION FORM

Card Information