EmailMe Form - AMPED MD

Date Time *
MM / DD / YYYY
Billing Contact Name *
First Last
Company *
Email *
Phone *
### - ### - ####
Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Payment Type
I would like to use the following type of payment account: *
Bank Account
Credit Card
Choose a Bank Account (1% fee) for ACH Payments or fill out the Credit Card (cc fee 3.5%) for your authorized payment with Elevated Business Marketing.
Bank Account ACH Payment Information
Name on Account
First Last
Bank Account #:
Bank Routing #: (9 digits)
Bank Account Type
Credit Card Payment Information
Credit Card

Card Number

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Name on Credit Card
First Last
Recurring Payments

Billing Date: 4th of the month

Package Details:
Month 1: $5000 and then Monthly Recurring at $2500/month
Individual Payments
Invoices for one-time payments.
I authorize Elevated Business Marketing, LLC. to charge my stored payment for individual invoices after individual approval.
I AGREE TO THE FOLLOWING:
Check each item below to approve the payment/service terms.
I authorize Elevated Business Marketing to charge my stored payment information on file for the purchases outlined above. My payment information details will be stored securely in my customer profile and will be used only for approved purchases.
Services include a 1-month setup period followed by a 3-month minimum term. The account then continues month-to-month and may be cancelled with 30 days' written notice, with the final month payable in full.
I agree to late fees of 5% or $25 minimum if payments are late, $29 NSF fees. Services may be suspended for overdue accounts.
I agree to receiving text messages from Elevated Business Marketing.
Terms of Service for Website Services and Privacy Policy for Elevated Business Marketing, LLC. is located at https://elevatedbusinessmarketing.com/terms
Signature *
Clear
Authorized Signature for Company

Bank Account ACH Payment Information

Credit Card Payment Information