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Secure Payment Portal

American Association of Swine Veterinarians

Please use this form only as directed by AASV staff.

Please complete all applicable fields...

Amount to pay:		$(US dollars)
Reason / explanation:

Contact / Membership information (“Ship to”)

Name

Title (E.g., Dr., Ms., etc.)
First: Middle:
Last: Jr, III:

Mailing address

Street address

City

State/Province

Postal (ZIP) code

Country

(USA may leave blank)

Telephone
(include area/city codes)

Business

Home

Cell/mobile

Email

(required)

Different “Bill To” address or email (to show on emailed receipt)

Name / Company

Address

Street

City

State/Province

Postal (ZIP) code

Country

(USA may leave blank)

Telephone

(include area/city codes)

Email

A duplicate of the receipt will be sent to this email address.

Hidden values (shown in testing) Amount due: Order form: CSRF token: reCAPTCHA Response:

PaymentSpring Response (shown in testing) Token ID: Card Type: Card owner name: Last 4 digits: Exp Month: Exp Year:

Total due: US $-.--
The total due is subject to review by AASV staff and availability of requested product/service(s). You will be notified if your request cannot be fulfilled.

Your payment will be processed securely by Nelnet Payment Services (privacy policy). Payment will be drawn in U.S. dollars.

REQUIRED credit card information Name on card:
Card number:
Exp date: /
Security code:
Card Postal/ZIP code:
Country:

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