PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

PayQuiq Invoice

Please review the charges below, contact Danielle Harris at dharris@payquiq.com with any questions.

If you are ordering mobile card swipe device(s) please fill out the fields in the form below regarding requested date to order and address/contact name devices are being sent to.

* Organization Name

Card Swipe Device Information

Requested date to order devices

Please allow a week for shipping
If renting specify what month(s) of rental

Address and Contact Name devices are being sent to

Rented Devices

I authorize PayQuiq to charge my card for additional months if my devices are not returned within a 30 day period

Yes

Max amount charged: $35/device

Recurring

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Total:

PayQuiq Invoice