Credit Card Payments

Name (as it appears on the card):____________________________________________  

Email address:_______________________________

Company Name (when applicable):___________________________________________

Credit Card:  Visa ___     Mastercard ____  Discover ____ AMEX___________

Billing Address: _________________________________________

 

City: __________________  State:______ Zip: ________

 

Card Number:__________________________________Expiration Date:__________

 

Three Digit Code:_________________ Amount:_______________

By signing below, I authorize Landlord Connection, Inc. to bill my account for the amount listed above:

Authorization Signature:_________________________________Date: ____________

 

You can fax or email this form to: 

Fax: 603-424-4032

Email: LLConnect@comcast.net

 

Landlord Connection, Inc                              

PO Box 1387

Merrimack NH 03054