Fill out this form and click the submit button to pay with your credit card. First Name: Last Name: Inspection Address: Inspection Date: Billing Address Billing Address: City: State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY Zip Code: Phone Number: E-Mail: Amount: $ Contact usPaul J. Thiele Tel (303) 517-0670 Member of