BREHM HAVEL & CO LLP
Secure Payment Form
Payment Summary:
Date:
02/07/23
Payment Amount:
Client Number:
Client Name:
Invoice#(OPTIONAL):
Customer IP:
3.235.25.27
Credit Card Information:
Card Type:
Visa
MasterCard
American Express
Discover
Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date:
MMYY
Card ID (CVV2/CID) Number:
[
What is the Card ID?
]
Billing Information:
Company Name:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Email Address:
NOTES:
Refund Policy:
Refund requests are reviewed individually by Management to determine refund eligibility. Valid refunds will be either credited to the customer's credit card account, or a check will be issued to the customer within two weeks of validation.