LIFS Payment – IINE Development

IINE Staff Member

Other Staff Member (Email)

Enter user's SF username (usually their email address)

Staff Email (calculated)

Payment made by:

Corporate AccountIndividual Contact

Client Information

First Name

Last Name

IINE Contact ID

Client Phone

Corporate Account

Account Name

IINE Account ID

Services

Fee Selection

Service Selection

Type

Service

Quantity

Unit Price

Subtotal

Total Amount:

Type of Payment

Send Receipt

Send Copy of Form Response by Email

Client Email

Account Email

Stripe Email

Form Response Email

Payment Information

Check Number

Billing Information

Street Address (Line 1)

Street Address (Line 2)

City

State

Zip

Payment Information

Name on Card

Credit Card Number

CVV

Additional Comments and Notes