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Merchant Payment Request
Merchant Info
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Address Line 2
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Preferred Method of Contact
Email
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Email Address
Confirm Email Address
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(Required)
Payment Type
Reason
Dr. Aponte's Car Allowance
Payment Amount
Frequency
One-Time Payment
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Payment Frequency
Payment Method
Net Invoice
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Invoice Upload
Max. file size: 2 GB.
Credit Card Processing Link
After submitting this request, you will receive an email with the ACH payment details to process the payment.
Bank Details
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Account Type
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Your Comments/Questions
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