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This is our Form of Payment Document for customers to fill out
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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 [email protected] 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