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		,
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
CVV Code - What is this?
Credit Card Security Code (3 digits for Visa, MC or Discover) (4 digits for American Express)
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: