Payment Form

Complete your payment, by filling out the form below.

Date

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Dues Discounted End Date

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Calculation Date Difference

If todays date is past “dues discounted end date”, difference is negative. If today’s date is before “dues discounted end date” difference is positive.

Name(Required)

First Last

Email(Required)

Practice Name(Required)

TIN(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Notes

Discounted Dues Owed(Required)

Dues Owed(Required)

Copy of Invoice

Max. file size: 2 MB.

Total

Credit Card(Required)

Card Details

Cardholder Name