Submit a form of payment

Do you want to put a credit card on file? Use this secure and discreet uploader to send the front and the back of your card.

Name

First Name

Last Name

Front of Card Upload (Accepted formats: jpg, png, gif, heic, or pdf. Max size allowed: 10MB)

FileField; MaxSize=10000KB; Multiple; addText=Upload_front_of_card

Back of Card Upload (Accepted formats: jpg, png, gif, heic, or pdf. Max size allowed: 10MB)

FileField; MaxSize=10000KB; Multiple; addText=Upload_back_of_card

Endorsement

By checking this box, I herby give consent for the use of my credit card in the intended manner.

✓ Yes, I grant permission for it to be used as authorized and intended.

Initials of card user

Date of upload

YYYY