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NNFA/NALA Payment Form
Contact Information
Unique ID
Facility/Company
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State
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District of Columbia
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South Carolina
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
*
Email
*
Invoice Number(s)
*
Please separate invoice numbers with a comma if paying more than one invoice.
Payment Amount
*
Total amount you want to pay on your account.
Total
$0.00
Billing/Payment Information
Copy the contact information into the credit card billing fields?
Yes
Note: Only do this if the credit card billing information is the same as the contact information.
Payment Total
$0.00
Cardholder's Email
*
Cardholder Name
Cardholder Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Credit Card
*
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
Security Code
Cardholder Name
Review/Confirm Your Information
Click "Previous" to make changes. Click "Submit" to process your payment. Both buttons are found at the bottom of this page. {all_fields}
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