Account Holder's Information
Name: %acctName%
Address: %acctAddress%
Apt: %acctApt%
City: %acctCity%
State: %acctState%
Zip Code: %acctZipCode%
Email: %acctEmail%
Recurring Payment Details
%wdsAccountHolderLabel% Account Number: %wdsAcctNumber%
Reference Number: %referenceNumber%
Payment Method: %paymentMethod%
%cardNumberLbl%: %cardNumber%

  1. I authorize %receiptCompanyName% to take payments from the account described above and on the dates and number of times described above. I also acknowledge that the orientation of ACH transaction from my account must comply with the provisions of U.S. Law. 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 payment. I understand that cancellations must be made in writing and I will not dispute merchant debiting my checking/ savings account, so long as the amount corresponds to the term indicated.

  2. I authorize %receiptCompanyName% to charge my account with the following fees when assessed and without further notice:
    (1) Broken appointment fee at $35.00 each:
    (2) Broken bracket fee:
         A. Metal bracket at $%metalBracketPrice% each
         B. Clear or gold bracket at $%goldBracketPrice% each
    (3). %lateFeeMsg%

  3. I acknowledge that any payment charges made by %receiptCompanyName% will apperar under '%receiptCompanyNameDBA%' name in my statement.

  4. Payments made before 3:00 PM PST will be applied to account that evening.

  5. I acknowledge that I will be charged for auto renewal on the payment method provided above 30 days prior to expiration of current plan


Signature: _____________________________________      Date: ___________________