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    Notice: Element 74 recently updated this Authorization form.

    Payment Information

    Multiple Invoices
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    Recurring Transaction

    Payer's Information

    Your Name*
    Address*

    Card Information

    A 3% convenience fee applies to payments made by credit card, debit card, or Google Pay.

    Bank Account Information

    Please Note: It may take up to 3 business days, excluding holidays for processing. Same-day processing and a specific withdrawal date are not guaranteed.
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    Total

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    ACH Payment Processing Information

    ACH information submitted through this form is entered manually into our electronic debit processing system and is not processed immediately upon receipt.

    Completed ACH authorization forms must be received by 12:00 PM (Noon) Central Time on the business day prior to the requested batch date.

    Forms received after the deadline will not be completed on the requested date.

    Insufficient funds or failure to timely approve ACH authorization by your bank's requested deadline may result in a bank fee, which will be the responsibility of the account holder.

    Element 74, Inc
    P.O Box 819, Cape Girardeau, MO 63702
    Phone : 573 803 2675 | billing@element74.com