Company Name(Required)Company Contact(Required) First Last Contact Email(Required) Phone(Required)Account #Insertion Order (IO)/Invoice #AmountCharge InstructionsSales Rep(Required)Select Account RepresentativeAlex RobertsCami BurkeEmily ChathamHaley MuseKate MartinKimberlee JonesKym Rock DavidsonLisa McLarenRebecca Young MitchellRhett TaylorSusan O'NealPayment Option(Required) ACH/E-Check Credit Card**A 3% processing fee will automatically be added to an invoice if a credit card is used for payment.Bank Name(Required)Name on Bank Account(Required)Remit Email(Required) ABA Routing Number(Required)Account Number(Required)Account Type(Required)Checking AccountSavings AccountAccount Classification(Required)Business AccountPersonal AccountCredit Card Holder Name(Required) First Last Credit Card Type(Required)Select Credit Card TypeMastercardVisaWe only accept Mastercard and Visa.Credit Card Number(Required)Expiration Date(Required)Remit Email(Required) Consent Keep on file to automatically process future orders at invoicing.Consent(Required) I agree to the authorization.By submitting this form, I authorize D Magazine Partners to charge the account stated above. This form will be in effect until written notice is given to the D Magazine accounting department.CAPTCHA
