Example of Submit Charges Here Page

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Nonworking Example of
Submit Charges Here


Charges to Submit:
Description of Charge:
Amount of Charge:
Is this a reoccurring charge?	yesnoIf yes, form will be completed automatically on future submissions, except for the card number.
Debit or Credit Card Information:
Card Type:	VISAMasterCardDiscover
Card Number:	numbers only
Exp. Date:	mm/dd/yyyy
Card Holder's Identifying Information:
Name on Card:
Client's Name, if different:
Relationship to Card Holder:

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