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Reg+ Credit Card Payment

CSR Name:
SR #
 
Customer Info:
Name:
Phone:
Email:
Best time to Contact:
 
Payment Info:
Name on Card:
CC Type:
CC#:
Exp. Date:
Billing Zip Code:
 
Domain Name(s): Invoice Number(s) and Amount(s) from BARS:
Name: Inv. # Amt.
Inv. # Amt.
Name: Inv. # Amt.
Inv. # Amt.
Name: Inv. # Amt.
Inv. # Amt.
Name: Inv. # Amt.
Inv. # Amt.