Electronic Referral Marketing
Credit Card Payment Request

Use this form only to request to pay by credit card. We will call you back at the number you provide to verify your credit card information unless you submit a verification form.

DO NOT include your complete credit card number.

You must be registered and previously placed an order.

Use the Tab Key to move between fields and not the Enter Key.
First Name:
 
Last Name:
 
Company Name:
Enter company if this is the name on the credit card.
Address:
 
City:    
State: Enter NO if NOT US address. Insure you include the correct state, province, zip and foreign zip. You are responsible for the correct information.
Province:
Country:
Zip: Enter 00000 if NOT US address
Foreign Zip: Non US enter your foreign zip
Phone:
We use 10 digits of your phone as your ID so make sure it is correct.

International, include all access codes.
Enter Referral Information Below
Please enter your email, 11 digit ID and Order Reference Number you created when you ordered. You can find your reference number on the email sent back to you confirming your order.
E-mail:

Use the email you registered with.
We will verify your registered ID and address on file with the address above when we call you.
Your ID:
11 Digits used with registration.		 Use Your Phone + 0
Use NUMBERS ONLY.
Reference: This is the number you created when you placed the order.  
5 digit credit card number: Enter the Last 5 digits of your credit card you want to use. DO NOT enter your full credit card number anyplace on this form.  
Comments:
Enter the best time to contact you and the name on the card.
Please be advised that different products and services have different warrantees and refund policies. You must pay for all shipping on any warrantee work. You must cancel within 14 days of order for a full refund. After that period refunds may be partially paid depending on product or service. We do not provide any credit card information to any outside party. Other personal information is used in house only and is used internally for commissioning purposes only. Your credit card will be paid to Genus Enterprises. We will contact you and identify ourselves as Genus Enterprises and include your reference information. You can leave a message or fax anytime at 406-646-6660 for us to call you back. If you fax this form then sign in the comments box with the name on the card. You may call us back, after we call you, at 406-646-6660 prior to providing your credit card number or sic code if you want to insure you are speaking to Genus Enterprises. Do not call the 406-646-6660 number for any other purpose or we will bill your account $35 as a service call. Your credit card will be billed immediately and your products will be shipped within three business days unless other information such as your advertising material is required before completing your order. We use this double check process for verification of credit cards because our product amounts are often $1000 or more. We know you want to know who we are and we want to know who you are. Our mailing address is 2933 W Central Ave #A Missoula, MT 59804. Our company is affiliated with 3demall.com, Genus Enterprises and Inter-Net-Working, Inc. Our company relationships can be found at www.electronicreferralnetwork.com/reports.
Press the Back Arrow Key on your confirmation page to return here after submitting this form if you need corrections or follow the links for other sites.

Paper Credit Card Form

RLM Program

Contact Us


You must return to the product page to order. This is not an order form. This is a request to pay by credit card.

Submission of this form is your signature to charge your credit card once we call and obtain your credit card number and other identification.



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