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Ver. 2.7 <br />VIA1111V rumjuwn�y. <br />'quv' ---' <br />MOnTniy <br />M"n <br />Numver Or Dills: 23,000 <br />Number of Cycles: <br />�4 <br />-Number of Installments: <br />,�v­eraqe lnvol�ce Amount: <br />Average <br />$250 <br />: <br />Highest Invoice AmountT$ <br />125,000 <br />fi�illfng We the (please select the applicable months below): <br />Mon OFeb OMar OApr OMay DJun 1.3 Jul 0 Aug 0 Sept OOct 0 Nov 0 Dec 2 All <br />0 1-f—iofh 0 Ilth-20th 0 21 af - 31d <br />OT ernpl2te I] Bill Print Vendor <br />INFOSEND, IPE <br />Hardware: Choose an item. QTY <br />Choose an �R FeW, L by: 0 Sales Rep C3 Operations <br />Per Unit Price: <br />-Provided <br />Shipping Addir <br />I ping 7-1 <br />------- <br />if jj",� <br />(if di!ttwenl than locaflar. address) <br />Total Due: $ <br />Services <br />4#1ect from the below to indicate <br />Item <br />�7-- �Vdlcl 1` <br />Fees <br />N the 3erytkce fee Willibo pold by the <br />Ilern <br />fq�r or N Biller will absorb fee, <br />Paid by Biller <br />0 Credit Card: -7 <br />Credit In' efc.,honge, fees, dues ossessments, + <br />Credit <br />t <br />Y with I Minimum <br />Minimum <br />,mum <br />--ff —EFIJACH-.LT$ <br />rd. Aujho�izatlo <br />Card: Authorization + %BPI <br />peritem <br />El <br />❑ —iFT/ACH: $ per item <br />0 Flax Pay ACH: $ —Pe rri t e rn <br />er-tern <br />El Flex Pay �Z�H $ per item <br />Item payer <br />Item Paid by Bii3er <br />Cl Credit Card: <br />[0 <br />Credit ruem+hangC, Pee;, dues assessments <br />with Minimum <br />Card: <br />Authorizallon 70M 0 <br />C1 EFTIACH; i Per <br />- - Per Item <br />/A H. $ <br />CH. $ <br />Cl Credit Card Service Fee: <br />7 <br />Max Cap for Credit Cards: ds' $ <br />F/AM Service Fee., <br />�tmfiv �esponse <br />C1 Paid by payer —�D Paid by Biller <br />WR Vendor <br />- IVR <br />0 Paid by payer Service Fee + S <br />7 S/Special Handling: <br />7— <br />0 Paid by Biller S T per item surcharge <br />I <br />1 �11712( <br />—16— -- <br />