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Page 1: Form of Payment

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

mailto:[email protected]

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