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1. Customer Information

Company Name *

Your Name *

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Email *

2. Payment Identification Information

Payment Type * One Time Recurring

Payment Currency * KYD USD

Paying On * Account Specific Invoice

Recurring Type *

Monthly Recurring Amount * Yearly Recurring Amount *

Invoice Number * Invoice Number

Ex. 1001,1002,1003,1004..

Total Amount *

Note: Please denote the total amount to be charged in this payment plan.

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CVV Number *

Card Expiration *

Notes

Please Note: A 4% processing fee will be added to your transaction.

I authorize Netclues to charge the credit card indicated in this form according to the terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

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Need a similar system for your business? We can help you, email us at sales@netclues.com and we will be more then happy to help.

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