Here's how it works
01. Edit your direct billing form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out the direct billing form
- Click ‘Get Form’ to open the direct billing application in our editor.
- Begin by filling out the ACCOUNT INFORMATION section. Enter your COMPANY NAME, TITLE, and CONTACT details including PHONE # and E-MAIL ADDRESS. Ensure all fields are completed accurately.
- Next, provide your BILLING ADDRESS along with the corresponding STATE, CITY, and ZIP code. Include any specific DEPT and ATTN NAME if applicable.
- In the CREDIT CARD INFORMATION section, select your card type (AMEX, VISA, MASTERCARD, DISCOVER) and fill in the CARDHOLDER’S NAME, CARD NUMBER, SECURITY CODE, and EXPIRATION DATE. Don’t forget to sign where indicated.
- Complete the CREDIT REFERENCES section by listing companies you have credit with. Include their CONTACT PERSONS, ADDRESSES, CITIES, STATES, and PHONE #s.
- Fill out BANK REFERENCES with your bank's name and account number along with a contact person’s details.
- Finally, review the certification statement at the bottom of the form. Sign it as AUTHORIZED SIGNATURE and print your name along with the DATE and TITLE before submitting.
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