A.N.D. Technologies Transaction Payment Page

	Customer payment information

First name:
Last name:
Phone number:
Email address:
Company name:

	Billing information

Address:

City:
State/Province:
Zip/Postal code:
Country:

	Transaction information

Transaction Type:
Transaction #:
Transaction Amount:
Notes:

	Payment information

Credit card type:
Card number:
Expiration date:
Cardholder name:
Card security code (CVV):

	Notice

	This is a secure online payment page; however, your payment will be handled by a person. All information submitted here will only be sent over a secure connection. An email will be sent to you immediately confirming that the order for payment has been received. Payments will only be accepted from the US and Canada, and from countries where there is not an authorized reseller.