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Essex Center For Rehabilitation
81 Park Street • Elizabethtown, ny 12932
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
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Amount
*
+ Convenience fee: 3%
on
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Residents Name
*
Residents Phone
*
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Credit Card Details
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Card Number
*
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*
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By clicking this form, you give Essex 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
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Routing Number
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Account Number
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Essex Center For Rehabilitation
81 Park Street
Elizabethtown, ny 12932
Tell: 518-873-3570
[response]
ID #[transid]
[created]
[cardholder]
[amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
