user's credit card expiration date, in MMYY format. Orders which contain expiration dates PRECEDING the order request date will not be accepted at the AGX Imaging Center.
Credit Card Expiration Date Help
(required)
user's credit card #. Any combination of spaces or '-'s may be used for convenience.
Credit Card Number Help
(required, if direct-account billing is not selected)
user's credit card to be billed. Choices are:
AMEX American Express
M/C Mastercard
VISA Visa
Credit Card Help
(required, if direct-account billing selected)
7-character code which was assigned to this user by AGX during the direct-account billing registration process.
Account Number Help
(required field)
user may pay for AGX products by credit-card, or may establish a direct-account by calling the AGX IMAGING SUPPORT number.
1-800-548-8558
1-617-890-8558 (in MA)
The direct-account # may only be used AFTER the user registers.
Method of Payment Help
This dialog box gathers information on how you will be paying for the services provided by Autographix.
Billing Information Help
Clicking the Cancel Button cancels the operation and the entries revert to the old values.
Cancel Button Help
Clicking the Ok Button signifies that the entries are accurate, and you wish to continue with the second part of the Input Form.