Tek Country Payment Collection Form

Tek Country Credit Card & ACH Collection Form

*This Is A Secure Form Made For Handling Sensitive Information Like Credit Card Numbers & Bank Info*

Credit Card or ACH

Credit Card ACH

Please Do Not Use ACH Unless You Have Talked To Us Prior

Name On Card

Credit Card Number

Card Security Code

Expiration Date MM/YY

Billing Zip Code

Email address

Bank Name

Routing Number

Account Number

Name On Account

Address Of Account Holder

Email address

Your information will be encrypted.