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Cooperstown Center For Rehabilitation
128 Phoenix Mills Cross • Cooperstown, NY 13326
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
$
Amount
*
+ Convenience fee: 3%
on
credit card
transactions
Final Amount
Residents Name
*
Residents Phone
*
Payment for Month
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Recurring Payments
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Credit Card Details
Pay with Check
Card Number
*
MMYY
*
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?
By clicking this form, you give Cooperstown Center For Rehabilitation permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
Account Holder
*
Routing Number
*
Account Number
*
Choose Account Type:
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Cooperstown Center For Rehabilitation
128 Phoenix Mills Cross
Cooperstown, NY 13326
Tell: 607-544-2600
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
