PayQuiq Invoice

Please review the charges below, contact [email protected] with any questions.

* Organization Name

Software Development Services $

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

If you prefer to send in a check please send it to:
Payquiq Inc.
2001 Granite Bar Way
Gold River, CA 95670

Recurring

E-mail

Enter your name and e-mail address for your confirmation

First Name

Last Name

Account

Online Fee:

Comments

Total: