Light Center Invoice Payments

Quote/Invoice Number(s)*

Company Name If Applicable

Name*

First NameLast Name

Email*

example@example.com

Invoice Total*

US Bank AccountCredit Card*

*Credit card payments are subject to 2% surcharge fee

2% Online Processing Fee

VISAMastercardAmerican ExpressDiscover

Payment Total

Final Payment Amount*

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Account Holder Name*

First NameLast Name

Financial Institution Name*

Routing/Transit Number*

Account Number*

Business checkingBusiness savingsPersonal checkingPersonal savings

By Clicking Submit, I (we) hereby authorize The Light Center Inc, hereinafter called COMPANY, to debit entries to my (our) account indicated above and the Financial Institution named above, hereinafter called FINANCIAL INSTITUTION, to debit same to such account. I (we) acknowledge the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Final Payment Amount For Email