Banking Information | Palm Springs Web Design

Secure Bank Information Form

The information on this form will be used to set up a monthly payment for your ongoing Hosting & Website Care Plan. The amount will be debited on the same day each month and you will be emailed a receipt.

Please choose a method of payment. You may use a monthly electronic AHC transfer (eCheck) or a Credit Card*.

*Please note that if you use a credit card a 3% service fee will be added.

"*" indicates required fields

Name on Account*

First Last

Email to send Receipts*

Phone*

Method of Payment*

Monthly Bank Transfer

Credit Card

Credit Card Information

Please fill in this information if you wish to have your monthly fee billed to a credit card on file...

Card Type*

Card Number*

Card Expire Date*

Three Digit CVC Code*

Service Charge*

I agree to a 3% service charge being added to my invoice to cover credit card processing

Bank Account Information

Please fill in this information if you wish to have your monthly fee paid as a monthly AHC transfer (eCheck)

Name of Bank*

Type of Account*

Personal Checking

Business Checking

Routing Number*

Account Number*

Billing Address*

Billing Address (Street Address) Billing Address (City) Billing Address (State) Billing Address (Zip / Postal Code) Billing Address (Country)

Authorization

Comments

This field is for validation purposes and should be left unchanged.

Secure Bank Information Form

Credit Card Information

Bank Account Information

Authorization

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