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Invoice detailsInvoice/reference numberPayment amount ($)

CardholderFirst nameLast nameEmail used on service requestPhoneBilling addressCityStateZIP code

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I authorize Mt Zion Tire Service LLC to charge the payment method entered for the amount shown. I confirm I am authorized to use it and agree to contact Mt Zion first about any billing concern before initiating a chargeback.

Card information is entered directly into Square’s secure form. Mt Zion does not receive or store the full card number or security code.