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You acknowledge and agree that you are authorized to use this payment method. You are authorizing BITS or BITS Payment Processing Affiliate to process this payment in the amount specified.
Please indicate the type of payment card you are using.
Please input the name as it appears on the payment card.
Please fill in your credit or bank card number.
Please indicate the card expiration month.
Please indicate the payment card expiration year.
Please fill in your billing zip code for this payment form.
Please input your card cvv or security code usually found on the back of the payment card.
Please input the invoice number that this payment should apply to.
Please fill in the payment amount for this payment in US dollars and cents.