Vericheck Test Payment Page
Secure Payment Form

 
Order Summary:
Order Date: 12/15/18
Order Amount:
Order Number:  
Customer IP: 34.228.30.69 
Description:
           
Checking Account Information:
Account Holder Name:
Bank Routing Number:
Bank Account Number:
Social Security Number:
Drivers License Number:
Drivers License State:
Billing Information:
Company Name:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Email Address:
     
Shipping Information:
Company Name:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Country:
Phone Number:
Authorization: By clicking the button to submit this form you authorize VeriCheck to debit the bank account whose information you provided above for a one-time payment. The amount of the payment will be for exactly the amount that is entered into this WEB Payment Form. After submitting this form you will have the ability to print or save a receipt to your computer
   


In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that VeriCheck may at its discretion attempt to process the charge again within 30 days, and agree to an additional $3.00 charge for each attempt returned NSF. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this bank account and will not dispute this transaction with my bank; so long as the transaction corresponds to the terms indicated in this authorization form. I understand that for any items that are disputed there will be a fee assessed in the amount of $25.00.