Payment Form Payment FormAchieve Revenue CC FormName* First Middle Last Phone Number*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment DetailsInvoice/Statement Number Payment Amount*Payment Type* Credit Card ACH / Check ACH InfoChecking or Savings?* Checking Savings Personal or Business?* Personal Business Name on Account* First Last Business Name* Routing Number* Account Number* Credit Card InfoCC Type* American Express Discover Mastercard Visa Card Number* CC Exp Month*Month010203040506070809101112Expiration DateCC Exp Year*Year2016201720182019202020212022202320242025202620272028202920302031CC Security Code* 3 Digits on backSecurity Code Amex* 4 Digits On Front Of CardNotesCredit Card Authorization*I authorize Get PEYD, LLC to charge the credit card for the amount indicated in this authorization form as payment for services rendered and I certify that I am an authorized user of this credit card. All transactions are non-refundable, and cannot be canceled once submitted. This authorization will remain in effect until Get PEYD, LLC charges the credit card provided for the balance due. At times, the amount due may vary slightly from the amount authorized initially in this form due to unexpected changes in the transaction. Get PEYD, LLC will charge the correct amount to cover the balance and upon request will, within 7 business days, provide an invoice or written proof to substantiate the charge. Charges may appear as one transaction or multiple transactions totaling the amount due. All cancelation or change requests are subject to Get PEYD, LLC's discretion. Please contact Get PEYD, LLC with any questions or concerns regarding this transaction or these terms before proceeding. I acknowledge that I have read and understood these terms, accept these terms, and agree to be bound by them. I have read and understand the above mentioned disclosure and accept the Terms and Conditions ACH Authorization*I hereby authorize Get PEYD, LLC to debit this bank account for the above-listed amount through the electronic Automated Clearing House (ACH) network. I certify that I am either a signer on this account or, for business accounts, an officer of the company with authorization to initiate this debit. I am aware that in the event that Get PEYD, LLC is unable to secure funds from my bank account for this transaction for any reason, including but not limited to, insufficient funds in my account or insufficient or inaccurate information I provided when I submitted this form for electronic payment, further collection action may be undertaken by Get PEYD, LLC including application of returned item fees to the extent permitted by law. If the payment is returned by my bank, I am still responsible for making a payment to Get PEYD, LLC. I understand that is an authorization to debit my account one time and is not a recurring authorization. However, if my payment is returned for any reason, I am hereby providing Get PEYD, LLC with the authorization to debit my account indefinitely until the balance due is paid. In such a scenario, Get PEYD, LLC reserves the right to debit my account for any amount up to and including the amount due. I also understand that payments are not changeable or cancellable once submitted. Please contact Get PEYD, LLC with any questions or concerns regarding this transaction or these terms before proceeding. I acknowledge that I have read and understood these terms, accept these terms, and agree to be bound by them. I have read and understand the above mentioned disclosure and accept the Terms and Conditions SignaturePEYD doesn't sell or share contact information with third parties Please send me occasional information about the airline and credit card rewards industry.