Credit Card Payment

Your Email Address:

Your Name:

LPS Contact Name:

Card Number:

Expiration Date:

Card Security Code:

This is the 3 digit code on the back of most cards; on American Express cards it is a four digit code printed on the front of the card.

Name on Card:

Card Billing Address:

Street:

City & State:

Zip Code:

Phone:

Fax:

For Services On or At:

Amount Quoted:

Credit card surcharge 3%:

Total to be charged to this credit card:

Payment Date:

Cardholder's Signature:

By re-typing my Signature and Date below, I am affirming that I am the above named person and that
I authorize LPS to charge the card listed above for the amount specified.

Re-Type Signature:

Copy fees of 25 cents per page will be incurred. I understand that additional charges may be added as they are incurred:

I Understand

Are you a Robot? If not, type the numbers
for "six zero four" in this box:

NOTE: Refund Policy: LPS is committed to providing our clients with a secure and comfortable payment system for online remittances. In the event of a billing error related to a credit card payment, LPS will provide a refund as applicable.
Understand that once LPS provides services to you, our fees are non-refundable. However, some cancellation requests may qualify for a partial refund. All requests for cancellation and/or refund consideration should be remitted in writing via email or fax to the accounting department.
Approved refunds will be credited back to the originating credit card. Fees are not dependent upon results.

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