Payment Data Form
Secure Computer Fax Number - (818) 301-2720
| Name | |
| Address* | |
| City, State | |
| Zip | |
| * Must be same name and address as associated with credit card | |
| Name on Card | |
| Card Number | |
| Expiration Date | |
| Security Code* | |
| Type (Visa, etc.) | |
| * Security Code is the 3 or 4 digit code on back of card | |
|
Fill in the requested information above, and FAX to us. This is a secure computer fax number and no one will be able to see your data but us. NOTE: There is a 3.25% fee to process the card - or you may simply send a check to the office along with the contract You may either fill it in on this page, and then print, OR print blank form and fill in by hand. |