REQUEST FOR PAYMENT
Date ________________________
Name _______________________
Company ____________________
Address _____________________
_____________________
In reference to the order placed on
__________________ (month & day) _____(year), we have received and
fulfilled your request. Payment on your
order is now due and payable. Please
send your payment in the form of check, money order, VISA, or Master Card. Please include your account/invoice number
with your payment. The total amount due
is _______________ ($________).
_____________________________
Accounting Department
Account number: ________________ Invoice Number: ________________
Amount Due: ____________________ Amount of payment: _____________
Form of payment:
Check, Money Order, Visa, Master Card (circle one)
Credit Card Acct. No.
____________ Exp.
Date: ____________________
