County Disposal Payment Form

On-Line Secure Payment For County Disposal by Credit Card
We accept Mastercard Discover and Visa only on our SECURE SERVER

Amount to be Paid:$
Numbers only, no dollar sign

* Please Select Your County:

Billing Information
Fill in the following information or make changes as necessary.
* = required fields  
Account Number
* First Name
* Last Name
* Address
Address 2:
* City
* State
Country
* Zip Code
Home Phone
* Email Address
Service Address
(If different from billing information)
Shipping Address Same As Billing Address
   
First Name
Last Name
Company
Address
Apt or Suite:
City
State
Country
Zip Code


* Credit Card Number
All credit card information is encrypted with SSL technology protecting against disclosure to third parties.

*
* Payment Method
Please select one of the following:

VISA
MASTERCARD
DISCOVER
* Expiration Date (mm/yy) MM YY
* Security Code
(3-4 Digit Security Code ID found after account number on back of card. Amex to the right above the numbers on front.)
* Name on Card
Order Comments or Questions
Caution: Please make sure to provide the exact address associated with your credit card that is on record with the bank that issued your card.
You may also send your comment in the box shown below.

Please read this information before sending your order. After you submit this Form, you will receive a computer-generated confirmation email that your order for payment was received.