Payments – Franklin C. Brown, Ph.D., ABPP

The following form may be used to make a payment using PayPal. You will have the option of using an existing PayPal account or major credit card (Visa, MasterCard, American Express, and Discover).

Payor's Name*
Please enter the name of the person making this payment.
First Middle Last
Are you making this payment on behalf of someone else?*
- No
- Yes
Name of Beneficiary*
Please enter the name of the beneficiary on whose behalf this payment will be made.
First Middle Last
Account Number (Optional)
Please enter the account number on your statement (if applicable).
Billing Address*
Please enter the address as it appears on the payor's credit card statement.

Street Address Address Line 2 City State ZIP Code
Payment Amount*
Please enter the amount of your payment (e.g., $50).
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Email for Receipt
If you would like a receipt, please enter the email address to which you would like it sent.
Enter Email Confirm Email
Name
This field is for validation purposes and should be left unchanged.