Photo PaymentComplete the form below to make a payment for Everlasting Memories PhotographyPhoto Payment If you are human, leave this field blank. Name on booking * First Last * Last Customer Number * Email * Phone Number * Billing Address * City * State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code * I'm paying for the following * Initial Deposit Final Payment Other Payment Payment Amount * amount to be charged during this transaction Payment Type * Credit Card Debit Card Card Type * MasterCard Visa Discover American Express Card Number * Expiration Month * 01 02 03 04 05 06 07 08 09 10 11 12 Expiration Year * 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 CVV Security Code * Last 3 digits on signature strip (4 digits on front of AmEx) Name as it appears on credit card (electronic signature) * By submitting, you certify that you are the cardholder and are authorizing Everlasting Memories to charge the listed amount to the credit card. I authorize Everlasting Memories to charge my credit card and agree to the payment terms on my reservation. * YesI authorize Everlasting Memories to use the above information to charge my credit card the stated amount. Completion of this form and checking this box signifies acceptance in lieu of my signature.