Credit Card/ACH Billing Information

Please select one of the following options:
Please initial below to approve montly payment option:


Billing Information

Method *

ACH/Digital Check Information

Credit Card Information

Visa, Mastercard, AMEX, Discover
The undersigned is the duly authorizing representative of (Household / Business):
Signature: *
Applicant agrees that all information is accurate and complete. Applicant also acknowledges that service may be terminated at Adam D Technology's discretion if any charges are declined or charge backs are claimed against any outstanding invoiced amount. Disputes to amounts invoiced or charged in the status of this card should be reported immediately to Current invoice payment is due upon termination of MIT or EOC agreement(s). *By signing this form, you authorize Adam D Technology to debit your card on file or bank account via ACH when an invoice becomes seven days overdue and remains unpaid.
Powered byFormsiteReport abuse
Secured by Formsite