"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.

"Expiration Date" field is required.

"Security Code" field is required.

Credit card number is required.

Billing
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Credit Card
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From
The Advantage Group
Advantage Group
43471 Ridge Park Drive, Suite B
Temecula, CA 92590
US
To
Trisha Frederick
1745 East Carleton road
Adrian, 49221
Date
January 2, 2018
Invoice Number
2641
Invoice Due
January 31, 2018
Invoice Total
$551.10
Balance
$551.10
  1. Tasks
    Rate
    Qty
    %
    Amount

    DIRECT PREMIUM BILLING

    $535.05
    1
    -3%
    $551.10
Subtotal $551.10
Total $551.10
Balance $551.10

Notes

Thank you; we really appreciate your business.