pp

Payment receipt will be sent once payment gets processed. Payment will be charged only after verification from Billing team.
 

customer information

*Center Code:
*Customer First Name:
First and Last name of the person that appear on the check only.Do not also include the middle initial.

*Customer Last Name:
*Phone Number:
*Street Number:
*Street Name:
*City:
*State:
*Zip Code:
*Email Address:
*Bank Name:
*Bank Routing Number: (first 9 digits on bottom of check)
*Bank Account(Checking) Number: (next to bank routing number)
*Re-enter Bank Account(Checking) Number:
*Check Number:
*Amount in USD:
*Best time to call for verification and Alternate number:
Please upload CHECK front copy duly signed:
Please upload CHECK backside copy:
* I hereby confirm that there are sufficient funds in my bank account mentioned above to ensure successful payment of above stated transaction. I understand that the transaction name that will reflect on my next bank statement will be :

‘Pankaj Pandit’

?>