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PAYMENT FORM
CLIENT INFORMATION

FORM SUBMITTER: What is your relation to the transaction?

*Client's First Name:
*Client's Last Name:
*Email:
*Inspection Address:
*City:
Special Concerns and/or Comments:
NOTE: This is not an automated billing form. Your transaction will be processed manually once the information is received at our office.
CARD INFORMATION
Visa
MC
Discover
AE

*CREDIT CARD NUMBER:

*EXPIRATION DATE - MONTH: YEAR:

*NAME ON CARD:

*SECURITY CODE: 3 digit code on the back of card
*BILLING ZIP CODE:
AGREEMENT: Cardholder acknowledges and authorizes payment for inspection services from Michael Leavitt & Co Inspections, Inc in the amount of the inspection fee and agrees to perform the obligations set forth in the Cardholder's agreement with the issuer of the Credit Card.
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 Copyright 1997-Present
 Michael Leavitt & Co Inspection, Inc.
 1378 N. Main St.
 Orem, UT 84057
 801-636-6816