iPosPays Payment Form

Amount: $0.00

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Description :

Card Number *

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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

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Address 1

Address 2

Tag 1

Tag 2

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Identity & Verification

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SSN*

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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 +13172911000 or Hollanddentalllc@gmail.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.

Holland Dental

12045 N Michigan Rd

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

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