Customer Payment By Credit Card

	*Arizona Premium Finance Co.*
	....The Driving Force in Premium Finance 800-873-2732

Customer Payments by Credit Card

Pay one payment by Credit Card or set-up a monthly automatic payment charged to your Credit Card.
Payment requests received by 2:00PM Arizona time will be processed the next business day. Payment requests received after 2:00PM Arizona time, will be processed within 2 business days.

You can call in this information to 800-873-2732.

Customer Information

First Name ( No ' or " )
Last Name ( No ' or " )
APFC Account Number		Your 8 digit account number
Address
City, State, Zip		, MA residents may not pay by Credit or Debit Card. Call 800-873-2732 to pay by Check
Home Telephone		212-555-6666
Work Telephone		212-555-6666
Email Address
Social Security Number		555-12-3456

Credit Card Information
Credit Card
Credit Card Number
Expiration Date mmyy
Name on Credit Card
Credit Card Billing Address
Credit Card Billing City, State Zip		,

Payment Options - select one option

Charge my Credit Card One Time for the option selected below.
- there is a convenience fee of 3% for Visa, MasterCard or Discover and 5% for American Express per payment for this service, $5 minimum fee.

Set me up for Automatic Charge every month for the amount due
- there is a convenience fee of 3% for Visa, MasterCard or Discover and 5% for American Express per payment for this service, $5 minimum fee.

Select either payment option described above:
Select Number of Payments to Pay: