Page 1


Check (invoice)

Check (no invoice)

Credit Card

Bank Wire

If you wish to pay by credit card, please complete the information below: Credit Card Type:


Master Card

American Express

Credit Card Number:

Expiration Date:

Name on the Card: Billing address for the Card:

Signature: If you would like to set up automatic payments, please contact for an enrollment form.

If you wish to pay by Bank wire, please use the information below: Beneficiary: Cornerstone Information Systems, Inc. 304 W. Kirkwood Ave, Suite 4 Bloomington, IN 47404 Checking account # 0087509091 Receiving Bank: Regions Bank #374 Bloomington, IN 47404 ABA Routing # 062005690 Swift Code: UPNBUS44

Form of Payment  

This is our Form of Payment Document for customers to fill out

Read more
Read more
Similar to
Popular now
Just for you