Secure Payment Form

Payment Information

Dealership Information

Email: (for pmt receipt)

Payment Information
Credit Card:
Name on Card:
Card #:
Card Type:
Exp Date: /
Pay by Check
Bank Name:
Name on Account:
Routing #:
Account #:

Recurring Billing:
I hereby authorize, Inc. to charge the indicated payment method on a monthly basis for the amount due under my agreement with, Inc. This Recurring Payment Authorization/Periodic Charge shall remain in force until cancelled by me in writing.

I hereby authorize, Inc. to charge the indicated payment method. I agree that this is a recurring charge that will be made as indicated above. To terminate the recurring billing process mail a letter to:, Inc.
PO Box 91537
Sioux Falls, SD 57109
I understand that all account cancellations must be made in writing. I will not dispute’s recurring billing with my credit card issuer so long as the amount in question was for services rendered prior to my canceling my account in the manner required. I guarantee and warrant that I am the legal cardholder and account owner for this credit card or bank account and that I am legally authorized to enter into this recurring billing agreement with, Inc.

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