Downs Rachlin Martin
Accounts Receivable
PO Box 99
St Johnsbury, VT 05819
802-748-8324

*Client/Company Name

*Client #:

*Cardholder First Name:

*Cardholder Last Name:

*Billing Address:

*Billing Zip Code:

Phone Number:

Payment Information

*Card Number:

*Expiration Date:

(MMYY format)

* CVV2:

Billing Information

*Payment Amount: $

*Invoice # or Purpose of Payment:

*Email Address for Receipt: