iPosPays Payment Form

Amount: $0.00

Payment Options

Description :

Card Number *

Expiration (MM/YY) *

CVV

Card Holder Name

Additional Details

Customer Name *

Tag 1

Customer VAT

Routing Number*

Account Number*

Account Name*

Routing Number*

Account Number*

First Name

Last Name

Zip Code

City

Select a state

Address 1

Address 2

Tag 1

Tag 2

Tag 3

Identity & Verification

DL Number

Select a DL state

SSN*

Birth Year*

Terms and Conditions

By clicking “Process” below you are authorizing this ACH transaction
By authorizing this transaction customer agrees that company named above may convert this transaction into an Electronic Funds Transfer (EFT) transaction to send via ACH debit to the bank account for the amount indicated above.
To revoke this authorization contact Customer Support at +17733628585 or dr.clause@brushstreetchicago.com within 48 hours prior to the Payment Effective Date.
Processing times may not allow for revocation of this authorization.
Additionally, in the event this ACH is returned unpaid, a service fee in the amount of $25.00 (or maximum allowable by law) will be charged to the bank account indicated via ACH.

Brush Street Dental Boutique

1457 N Halsted St Unit B 301

Amount: $0.00

SALE:

$ 0.00

$0.00

TIP:

$0.00

$0.00

$0.00

Food Amount:

$0.00

$0.00

Description :

Processing your request

Processing your request

VERIFICATION

CONFIRMATION

Error Occured

Payment Successful

Approved!

Payment Failed