Shaffer & Associates
Secure Payment Form
Payment Summary:
Payment Date:
01/26/21
Payment Amount
Customer IP:
3.237.205.144
Description:
Shaffer & Assoc. 1-888-261-5689
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:
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Account Information:
Account Number:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Email Address: