This is an authorization to allow the Third Party Administrator to deduct the fees associated with the products
you have purchased. There will be a bank draft for the one time registration fee of $0 in addition to the dues
of $0 on 8/19/2018. Monthly
dues will be automatically drafted thereafter starting on 06/06/2016.
You have selected the following products:
I, [Name Not Entered Yet], authorize the charge to my account for the amount
indicated above at the above indicated
frequency. I understand that I can cancel the product at any time and incur no further charges. I agree to
notify the merchant in writing of any changes in my account information or termination of this authorization
15 days prior to the next due date of the charges. For ACH debits to my checking/savings account, I understand
that because this is an electonic transaction, these funds will be withdrawn from my account as soon as the above
noted transaction date. I acknowledge that the origination of ACH transactions to my account my comply with the
provisions of US Law. I understand that cancellations must be made in writing and I will not dispute merchant
recurring billing with my bank or credit card company, so long as the amount corresponds to the terms indicated
in this contract.
By clicking the submit button, you will be enrolled in the selected products and your credit card or checking
account will be billed for the amount selected. By clicking the button you also agree that all information provided
is accurate and complete.