Credit Card Payment Form

*This form must be fully completed prior to submission.

File Number*

  -   example: 0123456789-789.

First Name or Company Name *

 

Middle Initial 

 

Last Name*

Daytime Phone*

Evening Phone*

E-Mail Address         

 

 Best time to call  

  1. Make a payment using a MasterCard or Visa credit card.

  2. Discover and American Express Cards  accepted ONLY on payments to U.S. Cellular accounts.

  3. Please choose the card type you will use, then enter the card number, card expiration date, address where the credit card bill is received, and the payment amount.

Choose the Credit Card Type*:

 

Enter the 16 Digit Credit Card Number* 

(15 digits for American Express):

 

Card Expiration Date* (Select two digit month, and two digit year* (MM/YY):

  /

Enter the 3 Digit Credit Card V Code* 

(the 3 numbers at the end of the signature line on back of card):

Enter the Address Where the Credit Card Billing Statement is Received:

Street Address*  
City or Town*  
State*  

Zip*

 
Payment Amount*: $  
  • All partial payments will be applied toward the balance due.
  • Acceptance of a partial payment does not constitute an approved payment agreement.
  • I Authorize Commercial Trade, Inc.  to process this payment.