View
212
Download
0
Category
Preview:
DESCRIPTION
This is our Form of Payment Document for customers to fill out
Citation preview
FORM OF PAYMENT
Check (invoice) Check (no invoice) Credit Card Bank Wire
If you wish to pay by credit card, please complete the information below:
Credit Card Type: Visa Master Card American Express
Credit Card Number: Expiration Date:
Name on the Card:
Billing address for the Card:
Signature:
If you would like to set up automatic payments, please contact accounting@ciswired.com for an enrollment form.
If you wish to pay by Bank wire, please use the information below:
Beneficiary:
Cornerstone Information Systems, Inc.
304 W. Kirkwood Ave, Suite 4
Bloomington, IN 47404
Checking account # 0087509091
Receiving Bank:
Regions Bank #374
Bloomington, IN 47404
ABA Routing # 062005690
Swift Code: UPNBUS44
Recommended