Payment Detail for Credit Card

*Surcharge 3.0%

Name

Phone

Project Address

Amount Owed

Plan

Card Brand

Name on Card

Card Number

EXP. Date

CVV

Address

Address 2 (Optional)

City

State

Postal Code

Country

Receipt Email Address

I consent IPR Associates & Environmental Inc. to charge this account for reoccurring payments bi-monthly until installment payment are paid in full.