Secure Form - CCC Billing - Connections Call Center

Please use this form to provide us with updated payment information. The information will be sent to us via this encrypted, secure form.

Name*
First Last
Company Name*
Phone*
Email*
Would you like an emailed receipt?*
Name on Card:*
Card Number*
Expiry*
Card Type:*
Additional Notes
Consent*
I agree to the below terms:
I, herewith authorize Connections Call Center to automatically process monthly payment of my invoices on the credit information provided.
I understand that Connections will take a credit card payment on the 15th of each month and a confirmation slip will be attached to my invoice when it is mailed.

Secure Form – CCC Billing