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LHB Insurance Brokerage Inc
176 N Main Street • Spring Valley, NY 10977 • 845-352-4000
Personal Information
Full Name
*
Address
Zip code
*
Phone Number
Email Address
*
Transaction Details
$
Amount
*
+ Convenience fee: 3.25%
on
credit card
transactions
Final Amount
Description
Credit Card Details
Pay with Check
Card Number
*
MMYY
*
CVV
?
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Credit & Debit Processing | Electronic Check Services | Gift & Loyalty Programs | Customized POS Solutions
LHB Insurance Brokerage Inc
176 N Main Street
Spring Valley, NY 10977
Tell: 845-352-4000
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
