Automatic Recurring Payment | Harms Refuse Online Payment

Payment Details

*This information is required

Name*

First Last

Account Number*

Name Where Service Was Provided*

Service Address*

Street Address Address Line 2 City State ZIP Code

Payment Amount*

Billing Details

*This information is required

Email

Phone*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*

Convenience Fee*

Price:

Total

$0.00

Understand & Agree To The Convenience Fee & Policies (Security, Privacy, Refund and Return Checks)*

I Understand & Agree

To Cancel/Update Recurring Billing*

I understand I am responsible for calling in and canceling the Recurring Billing. Please call the customer service at 402-488-9083

Your first payment will be made today once you submit this form. All following recurring payments will charge on the date you set this up (ex: first payment made on the 15th, you will be charged monthly on the 15th)*

I understand the recurring payment terms

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Automatic Monthly Credit Card Payment

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