Electronic Referral Marketing
Payment Verification

Use this form to validate your payment has been sent or to complete a credit card order.

Make sure you include your eleven digit ID number. (Phone + extension)

Use the Tab Key
to move between fields and not the Enter Key.
Last Name:
Last name ONLY for Security Purposes!		 We use your personal information submitted on your order matching your ID.
E-mail:
Your ID:

11 Digits
Use Your Phone + 0
Use NUMBERS ONLY.
You must use your
Registered ID
Paid By: I certify that I have made payment by the method indicated to the left to the appropiate Account. (Cash payments will post when received.)
Reference Number Enter the Reference Number you created for this Order

Fill in the appropriate fields below if you are paying by credit card. Use this form to send the remainder of your credit card information. Do NOT include your complete credit card number.

Warning - We will not process the credit card unless the card matches the name and address on your registration. Update your registration information FIRST if necessary.
Credit Card Number Warning - use ONLY your FIRST 12 digits on your Credit Card
Expiration Month Include the TWO digit month
Expiration Year Include the FOUR digit year

Security
Code

Include either your 3 digit code on the back of your credit card or the 4 digit code on the front of American Express.
Comments:



This information is submitted to a separate email address from your Registration and Orders to prevent hackers from obtaining all your credit card information.