Payer

Client Name		(as it appears in MM records)
Payer Name		(if payer is a different person than the client)
Contact Info		(provide a telephone number or e-mail address to use to contact you if there is a problem processing your payment)
Mailing Address		(fill in only if the address used by your payment method selected below is different than the client mailing address MM has on file)

Payment

Amount Due

U.S. $

(amounts quoted and billed by Manifest Marine are based on a discounted cash price; payments by check, the bank account debit method below and other forms of cash payment retain this discount; payments charged to a credit or debit card result in the loss of the 3% cash discount) (Refund Notice)

Payment Method

U.S. checking account       U.S. savings account                card:

Visa     Mastercard              Discover   American Express

		$ charge
Fill the three items below if  checking account or savings account is selected.		Fill the three items below if a credit        or debit card is to be charged.
Bank Name
Routing Number  (fill in 9-digit number on your checks that identifies your bank; for savings accounts ask your bank what number to use)		Card Number		(fill in 16-digit card number; 15 digits for AmEx cards)
Account Number  (fill in your bank account number as it appears on your checks)		Expiration Date
		Security Code	(fill in 3-digit code printed on back of card; for AmEx cards enter the 4-digit code printed on the front)

Special Instructions or Comments

Important Information

By submitting the foregoing information, I, the Payer, authorize Manifest Marine to record a debit entry against my bank account or payment card account in the amount specified.  I understand that this is a one-time authorization and that no further debits will be entered unless such future entries are explicitly authorized in the Special Instructions or separate instructions.  I understand that this debit entry may be entered as soon as it is received by Manifest Marine unless a requested delay is specified in the Special Instructions.  I understand that processing of this debit entry is not a guarantee of any particular insurance or other service and is only a credit on account with Manifest Marine unless such insurance or other service has already been arranged and confirmed.  I understand that this payment will be applied to the oldest unpaid charges.  Any agreement, authorization, written statement under penalty of perjury, or other record required must be retained as an electronic record that accurately reflects the information in the record, and is capable of being accurately reproduced for later reference, whether by transmission, printing, or otherwise.