Payment Authorization Form Sample Clauses

Payment Authorization Form. This contract will act as a Payment Authorization Form for all tuition payments, late fees and other charges that may be incurred.
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Payment Authorization Form. We agree to have all charges from Xxxxxx Transport Dispatch paid via one of the following (choose one and complete): Venmo, paid weekly to @Xxxx-Xxxxxx-2 Zelle, paid weekly to 000-000-0000 Charges not paid in a timely manner may result in discontinued services. I agree that all information provided is accurate and complete. I, also, acknowledge that all orders may be immediately terminated at Xxxxxx Transport Dispatch's discretion. Disputes to amounts invoiced should be immediately reported to xxxxxxxxxxxxxxxxx@xxxxx.xxx. Change in status of this card can also be reported to xxxxxxxxxxxxxxxxx@xxxxx.xxx. I wish to authorize the purchase of services from "Xxxxxx Transport Dispatch" using this Payment Authorization Form. I agree that I will pay for this purchase and indemnify the hold of "Xxxxxx Transport Dispatch" and its agents harmless against any liability pursuant to this authorization. This authorization is to remain in full force and effect until either terminated by Xxxxxx Transport Dispatch or written notice of cancellation from me, given in such time and manner as to allow the company a reasonable opportunity to act on it. The undersigned is the duly authorized representative of the company listed above: Print Name: Signature: _ Date: Xxxxxx Transport Dispatch 000 X Xxxxxxxxx Xx Xxxxxx, XX 00000 000-000-0000 EQUIPMENT LIST – ONE PER TRUCK Truck description: Trailer deck length x width, and ramps description: Trailer height from ground to top of deck: Weight trailer can be loaded with: Any special certifications (i.e. HAZMAT, TWIC, etc.): Equipment description (i.e. tarps #, size, drop, chains, etc.): Factoring company, address, phone number, contact, & login: US Citizen: Yes No US Resident: Yes No Clean Background: Yes No Driver info, if different from owner: (copy of driver’s license, email, phone) Personal Protective Equipment (PPE): At all times, you must keep all PPE with you (long pants, steel toe shoes, safety glasses, hard hat, & safety vest). If we must come off of a load due to driver not having the proper PPE, it will result in a charge to driver equal to 10% of the total line haul for that load (i.e. dispatch fees still apply). Please sign here to acknowledge that you agree to these terms:
Sample 1

Related to Payment Authorization Form

  • Payment Authorization I authorize Xxxxx Management to collect payment of the application fee and application deposit in the amounts specified under paragraph 3 of the Disclosures.

  • Payment Authorization and Payment Remittance By providing the Service with names and account information of Billers to whom you wish to direct payments, you authorize the Service to follow the Payment Instructions that it receives through the Site. In order to process payments more efficiently and effectively, the Service may edit or alter payment data or data formats in accordance with Xxxxxx directives. When the Service receives a Payment Instruction, you authorize the Service to debit your Eligible Transaction Account and remit funds on your behalf so that the funds arrive as close as reasonably possible to the Scheduled Payment Date designated by you. You also authorize the Service to credit your Eligible Transaction Account for payments returned to the Service by the United States Postal Service or Xxxxxx, or payments remitted to you on behalf of another authorized user of the Service. The Service will attempt to make all your payments properly. However, the Service shall incur no liability and any Service Guarantee (as described in Section 3 of the Bill Payment Terms) shall be void if the Service is unable to complete any payments initiated by you because of the existence of any one or more of the following circumstances:

  • Authorization, Etc This Agreement and the Notes have been duly authorized by all necessary corporate action on the part of the Company, and this Agreement constitutes, and upon execution and delivery thereof each Note will constitute, a legal, valid and binding obligation of the Company enforceable against the Company in accordance with its terms, except as such enforceability may be limited by (i) applicable bankruptcy, insolvency, reorganization, moratorium or other similar laws affecting the enforcement of creditors’ rights generally and (ii) general principles of equity (regardless of whether such enforceability is considered in a proceeding in equity or at law).

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • Information Release Authorization Throughout the Term, you authorize Homefield Energy to obtain information from the DSP that includes, but is not limited to, your account name, account number, billing address, service address, telephone number, standard offer service type, meter readings, and, when charges hereunder are included on your DSP bill, your billing and payment information. You authorize Homefield Energy to release such information to third parties, including affiliates that need to know such information in connection with your Retail Power service. These authorizations will remain in effect as long as this Agreement is in effect.

  • LEGAL AUTHORIZATION (a) The Sub-Recipient certifies that it has the legal authority to receive the funds under this Agreement and that its governing body has authorized the execution and acceptance of this Agreement. The Sub-Recipient also certifies that the undersigned person has the authority to legally execute and bind Sub-Recipient to the terms of this Agreement.

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