Credit Card Authorization

By signing this authorization the client authorizes New York Mutual, Zeus, or its affiliate to charge or collect the payment amount. The client also acknowledges that this payment is 100% non-refundable. If the payment is not honored by the financial institution, or the incorrect banking information is entered, a service fee of $30 will be charged.

Purpose of Charge*
Other*
Select Method of Payment*
- Credit Card/Debit Card
- eCheck
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address City State ZIP Code
eCheck
Name on Account Bank Name Routing Number Account Number Account Type
Please enter the following information EXACTLY as it appears on the checking account statement.
Full Name*
First Last
Address*
Address Line 1 Address Line 2 City State ZIP Code
Phone*
Your Email*
Used to send a copy of this transaction
Subject Property Address*
Street Address City State ZIP Code
Date
Signature*
Amount*
Please refer to your most recent invoice for the correct payment amount.
Memo

* Indicates a Required Field

Terms and Conditions