Hosted Payment Page

Payment:

Clear Card Information

Name on Card *

Card Number *

Security Code *

Exp. Month

Exp. Year

Name On Check *

Account Number *

Routing Number *

Check Number

Billing Address

(all fields required unless noted)

First Name *

M.I. (optional)

Last Name *

Address 1 *

Address 2 (optional)

City *

State

Zip Code *

Phone (for billing-related questions) *

Disclosures

You are authorizing MindSource Center to process a one time payment in the amount of $300.00 from your credit/debit card listed above.

E-mail for Confirmation

E-mail Address

Your privacy is important to us
This is just for confirmation of payment

Confirm E-mail Address