Contact: show +
Business Name
First Name*
Last Name*
Title*
Mailing Address Line1
Mailing Address Line2
City*
State*
Zip*
Email*
Confirm Email*
Phone*
Extension
Fax
Billing: (same as above) show +
First Name *
Last Name *
Email *
Billing Address Line1
Billing Address Line2
City *
State *
Zip Code *
Payment Information: show +
Payment with
Credit Card Check
ACH - Checking Remittance Information: show +
I understand that all payments made on my EzPayDr.com account, minus the processing fee, that are cleared will be sent to my checking account via the secure online (ACH) Automated Cleaning House system every Friday.
Account Number *
Routing Number *
Name on Account *
Check Type *
*I understand that on the 28th of each month my credit card or checking account will be debited for the monthly membership fee and for any additional costs.

*   By clicking the submit button below, I acknowledge and agree as its authorized officer and/or on behalf of myself as an individual applicant, I have read the Terms and Conditions, and that the company and I will both be bound by the terms of this agreement.

I have read and agree to the Terms and Conditions. (RPS.OPP.03.06.14)