Corinne  Secure Payment Form

Client Information:

First Name
Last Name
E-mail
Please describe the service(s) and/or product(s) you wish to pay for:
Description:
Please write the amount you wish to pay:
Payment Amount
GTQ

 
Para su seguridad esta transacción está siendo procesada en un "servidor seguro".
A continuación sírvase llenar los espacios con la información requerida por el banco local para procesar su pago con tarjeta de crédito.
For your protection this transaction is being processed through a "secure server".
Please fill out the blank spaces required by the local bank in order to process your credit card online payment.
 

Credit Card Information:

Cardholder's first name: 
Cardholder's last name: 
Type of Credit Card: (If applies)
Credit Card Number: (If applies)
(Do not use space or any other character in between numbers)
Expiration Date:  /    month / year   (If applies)
Security Code CVV   (Frecuently located at the back of your credit card)
Card billing address: 
City: 
State:    (Only USA)
County: 
ZIP Code: 

Invoice Information:

Name
Address
NIT
(
if are not a Guatemalan Resident please type in the following "CF")
Additional Information
Is sent as a gift?: Yes  Not
Address where the gift is sent:
Phone of buyer:

NOTE:We reserve the right to review that all the information filled in this form is correct.

NOTA: Una vez hace la solicitud para autorizar el pago con el banco , favor NO refrescar la pagina ni regresar utilizando la tecla "Back" de su navegador, espero que termine el proceso.



 

 

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