General Treasury Form

Payor Information

First Name*

Last Name*

Address 1*

Address 2

Country*

City*

State*

ZIP*
(99999 or 9999-9999)

Phone*
(555-123-1234)

Email

Organization Name*
(as shown on invoice)

Internal Information

Internal Contact*

Internal Email*

Department*

Speedtype*

Account*

Other

Transaction Description*

Amount* (9.99)

Billing Information

Same as Payor Information

First Name*

Last Name*

Organization Name

Address 1*

Address 2

Country*

City*

State*

ZIP*
(99999 or 9999-9999)

Payment Information

Payment Type

Credit Card
Electronic Check

Credit Card Information

Card Type*

Card Number*
(no spaces)

CVV2*

Expiration Month* Expiration Year*

Electronic Check

By marking this checkbox, I am authorizing the entered bank account to be charged for the payment amount entered. As payor, I am authorized to conduct transactions from the entered bank account and all information entered is valid.

Rounting Number*

Account Number*

Account Type* Checking
Business Checking
Saving

Bank Name*

Name on Account*