Individual "Type & Save" Form Purchase

cardholder first and last name, exactly as on the card
Purchase Description	Individual Form Purchase - $9.95 You have selected MI - (wc337) WC-337 Notice of Exclusion - Not available online. To obtain a copy of the form, contact the Compliance and Employer Records Division at (517) 284-8922. . Please note! Due to the electronic nature of this product, all form purchases are final and non-refundable. Please make sure this is the form you want.
Payment System	Secure Credit Card Gateway for Visa, MC or Amex (via Authorize.net) The Type of Card used will be recognized by your Card number
Cardholder Name *
Company Name or Contact Name
A name to reference for this transaction if other than the cardholder.
Phone Number
(Optional - this is only used by tech-staff, if for example you should have difficulty downloading a form)
Credit Card Number *
example: 1111-2222-3333-4444
Card Expire *
Address Info (must match your credit card statement delivery address)
Street Address *
City *
State *
ZIP *
Email *
Country	United States
Please enter the letters displayed:

Please note that due to the electronic nature of our product, all form purchases are final.