Company
First Name
Last Name
Email
Total Amount to pay
$
CC Fee
$
* A 2.5% fee is assessed to credit transactions.
If you are interested in paying via ACH please contact
julie@mattinglylowvision.com
Invoice(s)
*Please only pay invoices that include s/h, tax, etc. Web orders are
not
invoices
Payment Method
Credit Card
* funds can take 5 days to reach us
Name on Card
Billing Address
City
State/County
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
Zip
Phone
Credit Card Information
Credit card
Visa
MasterCard
American Express
Discover
Card number
CVVS
Expiration date
1
2
3
4
5
6
7
8
9
10
11
12
/
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Routing Number
Account Number
Check Number
Comments:
Submit
Submit
Processed by:
