PAYMENT ~ Student & Staff Charges

Name*

First NameLast Name
Email*
What are you paying for?*

Axium Dispensary StatementClinical Replacement InvoiceLost Keys/FOBS ($25)ID Badge Replacement ($15)Faculty Owned Mobile Phone PaymentsUTORMFA Hardware Token ($19)
Axium provider code*
What is your invoice total amount?*
Enter Dollar Amount Above
Item subtotal
Tax subtotal
Invoice Total
Financial Info

Checkout*

CADAmount

Credit Card (Visa, Mastercard, Discover, and Visa Debit accepted)
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year