Payment Form

Order Information

Company name:	Customer ID:	New
First name*:	Last name*:
Phone:	Alt phone:
Email:	Alt email:

Payment Information

Invoice number:
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Credit Card

ACH (eCheck)

Credit card accounts (optional)


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Card number*:		CVV2 Code*:
Expiration date*:		What's This? CVV2 Code is the 4 digit number printed above your American Express Card account number on the front of your card or the last 3 digits of the number located on the back of your Discover, MasterCard, or Visa card. This number is not required, but you have the option to enter it as an additional security protection.
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Billing Address

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Address 2:
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Terms and Conditions

I authorize the company named on this web form to debit the bank account or credit card indicated in this web form, for the noted amount on today's date. This payment is for the goods and services noted on the web payment form. I understand that returns, refunds and cancellations are not permitted, however exceptions may be made on a case-by-case basis. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. I agree that payments for billing schedules with common bill dates may be consolidated into a single payment. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the company named on this web form may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card or bank account, and that I will not dispute the payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.

I accept the terms and conditions

PANGUITCH CITY CORP
25 S 200 E
Panguitch, UT 84759
(435) 676-8656
carla.panguitchcity@gmail.com
http://www.panguitch.com

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