General Treasury Form

Payor Information

First Name*

Last Name*

Phone*

Email*

Organization Name* (as shown on invoice)

Address*

Address 2

City*

State*

Zip*

Country*

Internal Information

Internal Contact*

Internal Email*

Department*

Speedtype*

Account*

Amount*

Transaction Description*

Other

Billing Information

Same as Payor Information

First Name*

Last Name*

Organization Name

Address*

Address 2

City*

State*

Zip*

Country*

Payment Type

Credit Card

Electronic Check

Credit Card Information

Card Type*

Card Number*

CVV2*

Expiration Month*

Expiration Year*