Secure Online Payment

Intercity Services Online Payment

Invoice Number:

Payment Amount:

Billing Information:

First Name:

Last Name:

Address:

City:

State:

Zip/Postal Code:

E-Mail:

Telephone:

Credit Card Information:

Credit Card:

Credit Number:

Security Code:

Expiration Month:

Expiration Year:

By submitting this payment form, I hereby authorize Intercity Services Inc.
to charge the credit card as indicated above.

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