Submit Payments – DARIUS GOWNS

Buyer Information

Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code *

Country

Email Address *

Phone Number

Signature *

I hereby authorize Darius Cordell Fashions, to electronically debit my external account (and if necessary, to electronically credit my external account to correct erroneous debits) with the card information submitted, in order to make a payment on my invoice at the specified amount above.

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