Relix Payments

Order Information
Please refer to information on the Relix Sales Order Agreement.
Sales Order Number*
Sales Rep*
Company*
Campaign
Billing Information
Name*
First Last
Company
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Rate & Payment Information
Total Amount to Bill*

Enter the amount to pay, in USD
Rate
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
For any billing related inquiries, please contact Eddie Chaves at (646) 674-1839. All payments are handled securely via Authorize.net

Order Information