HALLE OIL - SECURE PAYMENT REQUEST FORM
All fields are required! Cash discounts are not allowed on Credit or Debit card payments!
First Name :
Last Name :
Home Address :
City, State, Zip :
Billing Address :
City State, Zip :
Billing Phone :
Email Address :
Amount :  $	Cash discounts are not allowed on credit or debit cards.
Card :	Visa MasterCard Discover
Card Number :	Card Security Code (located on back)
Expiration Date :	Month:   Year:
Note :
	This is not an instant payment. We use our secure server to safely receive your credit card information. A member of our staff will process your payment manually.