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PAYMENT METHOD: Please select only one option and complete the applicable information below <br />® Charge my credit card (please complete the below Credit Card Information below) <br />^ Set up direct billing to my bank account via ACH (please complete the ACH Information below) <br />^ Other billing arrangement (please complete the separate form, if attached) <br />PAYMENT DETAILS: <br />Amount of Payment*: $5,000.00 <br />Amount billed is not inclusive of sales taxes, if applicable. <br />Frequency of Payment: ®One time payment ^ Monthly Recurring <br />CREDIT CARD INFORMATION (please complete only if you selected payment by Credit Card): <br />Signers Name and Title: <br />Credit Card Type: <br />Credit Card Number: <br />Expiration Date: <br />Name on Card: <br />Security Code: <br />This is a debit card: <br />(3 or 4 digits on front or back of card) <br />^ Yes ^ No <br />ACH INFORMATION (please complete only if you selected payment by ACH): <br />(A blank, voided check must be attached) <br />Bank Account #: <br />ABA Routing #: <br />Bank Name: <br />City: <br />State: <br />Zip Code: <br />Changes to your ACH Account: Should you wish to discontinue the ACH option and switch to the Credit Card option, please <br />notify your First Amedcan RES Atxount Manager in wdting and allow thirty days for processing. <br />CREDIT CARD AND1OR ACH PAYMENT AUTHORIZATION (as applicable): <br />You, as Authorized Signature, authorize FACL to proceed with processing your company's order per the above <br />listed pricing and payment details using the EFTlcredit card or ACH payment option as referenced above. <br />Authorized Signature Printed Name & Title <br />important details about the productslservices you are ordering: <br />Page 2 of 4 <br />FAQ. Standard Pricing Proposal <br />Version Date: 11.07.07 <br />