"First Name" field is required.

"Last Name" field is required.

"Street Address" field is required.

"City" field is required.

"ZIP Code" field is required.

"State" field is required.

"Country" field is required.

"Cardholder Name" field is required.

"Card Number" field is required.

"Expiration Date" field is required.

"Security Code" field is required.

Card Or Magstripe Required

Billing

First Name *

Last Name *

Street Address *

City *

ZIP Code *

State *

Country *

Credit Card

Cardholder Name *

Card Number *

Expiration Date *

Security Code *

Billing

First Name *

Last Name *

Street Address *

City *

ZIP Code *

State *

Country *

Credit Card

Cardholder Name *

Card Number *

Expiration Date *

Security Code *

Invoice 6402

Pay Invoice

From: Ohel Basya
Ohel Basya
83 Mivlal Ln
Highland MIlls, NY 10930
US

To: הירש שלמה

Date: July 9, 2021

Invoice Number: 6402

Invoice Due: July 23, 2021

Invoice Total: $36.00

Balance: $36.00

Task

Rate

Qty

Amount

פר’ בלק שלישי

$36

1

$36

Notes

Checks paypable to: Cong. Khal Milval-Serpi 83 Milval Lane Highland Mills New York 10930

Terms

Please review your invoice and make payment at your earliest convenience.