EmailMe Form - Ampersand Credit Card Authorization Form

** Please Note **

The Ampersand Group is the credit card merchant name
that will appear on your credit card statement

Please fill out all the information below and this information will be securely sent for processing

Copy of the PAID invoice will be sent to the address below unless otherwise instructed:
Name on card: *
Email Address for Paid Invoice: *
Invoice Number to Pay: *
Authorized Amount
Company, if applicable:
Phone No: *
### - ### - ####
Fax No:
### - ### - ####
Must match your billing statement: *

Street Address Mail Stop/Apt/Suite City State / Province / Region Postal / Zip Code
Credit Card *

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Your signature: *
Clear
I understand my credit card statement will say Ampersand Group as the merchant for this transaction.