PLEASE COMPLETE THE INFORMATION BELOW. I _____________________________________ authorize Harts Events to immediately charge my credit account a date-hold deposit equal to half of my standard rental fee. This payment is for my event on ____________________________. The remainder balance will also be charged to this card if other payment arrangements have not been made within 2 business days of your event. If you would like to use an alternative payment method (check, additional credit card, cash) for the space rental fees balance, bar costs, catering, equipment, furniture, and/or miscellaneous costs, please check here . Please note that if you choose to use an alternative form of payment, payment timeframe remains the same. if the alternative method of payment has not been received by the due date the original credit card will be charged. Check _________ VISA MASTERCARD DISCOVER AMEX Credit Card Number: Expiration Date: Security Code: Name: (as it appears on card) Billing Address: Please note: All transactions will be subject to a 2.75% processing fee for Visa, Discover, Mastercard, and American Express. SIGNATURE _________________________________________________ DATE __________________ . I authorize Xxxx'x Events to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the event described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. Alcohol Policy All local, state, and federal laws concerning the serving and consumption of alcohol will be strictly enforced and are the sole obligation of the Client A client- hosted NON cash bar may be provided for your guests. Absolutle no monies may be tendered for alcohol dispursed at your event. Drink tickets may be sold prior to the event. No alcoholic beverages will be served to anyone under the age of 21 at any time. A preapproved, insured bar tending service must dispense all alcoholic beverages unless the Client signs the liability declaration assuming all liabilities solely from this event. If using a bartending service a copy of their Liquor Liability Insurance must be submitted prior to the event date. No alcoholic beverages are allowed outside of the venue hall at any time. Drunkenness wil not be tolerated and violators will be asked to leave the property. Failure to abide by this Alcohol policy may...
PLEASE COMPLETE THE INFORMATION BELOW. I (full name) authorize Arlington Ridge Golf Club to charge my bank account indicated below by the 5th of each month for payment of my monthly billing statement. Signature Date PLEASE SEND MY MONTHLY STATEMENTS TO BELOW Email Address Home Address Both Member understands that this authorization will remain in effect until they cancel it in writing, and agrees to notify Arling ton Rixxx Xxlf Club in writing of any changes in their account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment date falls on a weekend or holiday, the Member under‐ stands that the payment will be executed on the next business day. In the case of a Transaction being rejected for Non‐Sufficient Funds (NSF) Member understands that Arlington Ridge Golf Club may at its discretion attempt to process the charge again within 3 days. Member agrees to an additional $25.00 charge for each attempt returned NSF. NSF charges will be initiated as a separate transaction from the authorized recurring payment. Member acknowledges that the origination transactions to Member’s account must comply with the provisions of U.S. law. Member agrees not to dispute this recurring billing with Member’s bank so long as the transactions correspond to the terms indicated in this authorization form. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Name on Account: Account/Card Number Exp CVV Billing Zip Code:
PLEASE COMPLETE THE INFORMATION BELOW. NAME ENROLLMENT STATUS (circle one for each child): Child #1 FULLTIME PART-TIME Child #2 FULLTIME PART-TIME Child #3 FULLTIME PART-TIME I have read and understand the Xxxxx Kids Academy Family Handbook and agree to pay every other Monday as outlined in the Tuition Express Withdrawal Schedule provided to me at the time of registration. I also understand that the registration fee of $40 for each child will be deducted upon submission of this agreement. Furthermore, I agree to provide a completed Tuition Express Form to register with Tuition Express. Parent/Guardian Name (Printed)
PLEASE COMPLETE THE INFORMATION BELOW. I Xxxxxx Xxxxx authorize VStock Transfer, Inc. to charge my bank account (full name) indicated below on or after 9/27/16 (date) ID Information ID Type Number Country State/Province Billing Information Billing Address Phone# City, State, Zip Email Account Type: ☐ Checking ☐ Savings Name on Acct Bank Name Account Number Bank Routing # Bank City/State Credit Card Information Card Type Visa 0000 0000 0000 0000 07/20 Credit Card Number Expiration Date CVV Code 613 * Card Verification Value Code (CVV): CVV is a new authentication procedure established by credit card companies to further efforts towards reducing fraud for internet transactions. For Visa, MasterCard, and Discover cards, the card code is the last 3 digit number located on the back of your card on or above your signature line. For an American Express card, it is the 4 digits on the FRONT above the end of your card number. As an authorized representative of the above mentioned company, I hereby authorize VStock Transfer, LLC to maintain the above referenced credit card on file and to use such card for each transaction with VStock Transfer on behalf of the above referenced company unless otherwise instructed by the card holder. Signature Print Name Date Exhibit D CERTIFICATE OF APPOINTMENT OF VSTOCK TRANSFER, LLC AS TRANSFER AGENT AND REGISTRAR By StreamNet Inc. Nevada. corporation (the “Company”),
PLEASE COMPLETE THE INFORMATION BELOW. I authorize The Old Post Office Museum and Art Center to immediately charge my credit account a date-hold deposit of $100 . This payment is for my event on . If you would like to use an alternative method of payment (check, cash, or debit) for the space rental please check here . Please note that if you choose to use an alternative form of payment, payment timeframe remains the same. If the alternative method of payment has not been received by the due date the original credit card will be charged. Billing Address City, State, Zip Email Billing Phone Visa Mastercard Discover AMEX Cardholder Name Account Number Exp. Date CVV2 Number Signature Date
PLEASE COMPLETE THE INFORMATION BELOW. I ____________________________ authorize VStock Transfer, Inc. to charge my bank account (full name) indicated below on or after ___________________.
PLEASE COMPLETE THE INFORMATION BELOW. I authorize IP to immediately debit/charge the account provided below for the amount of the non‐refundable date‐hold deposit of $ . Date‐hold deposits are non‐refundable. This deposit payment is for the event described above. You further authorize IP to debit/charge the account for any payment obligation due under this agreement, including but not limited to, (i) the rental fee, 14 days prior to the event; (ii) Bar, catering, equipment, furniture, and other miscellaneous costs, 10 days prior to the event; and (iii) any other costs or fees as they become due pursuant to this agreement. You may choose to use an alternative form of payment. However, the payment timeframes remain the same and your account below will be charged accordingly if an alternative form of payment is not received, and you hereby authorize this account to be charged any such amount due. Billing Address Billing Phone City, State, Zip Email Account Type: Visa MasterCard AMEx Discover Cardholder Name Account Number Expiration Date (dd/YY) CVV2 Number (3 digit number on back of Visa/mastercard or 4 digits on front of amEX) SIGNATURE DATE
PLEASE COMPLETE THE INFORMATION BELOW. I authorize Sierra Vista Wines, LLC to immediately charge my credit account a date- hold deposit of 50% of the costs associated with my event rental fee. I acknowledge date-hold deposits are non-refundable and if my event is within ten (10) days of the submission of this form, I acknowledge Sierra Vista Wines, LLC will be executing withdrawal of 100% of the costs associated with the venue booking. This payment is for my event on . The space rental fees balance will also be charged to this card the day of your event prior to any room set up. Check here if you would like to use an alternative payment method (check, additional credit card, cash) for the space rental fees balance and/or miscellaneous costs. Please note that if you choose to use an alternative form of payment, payment timeframe remains the same. If the alternative method of payment has not been received by the due date the original credit card will be charged. Billing Address: Billing Phone: City, State, Zip: Email: Account Type: Visa MasterCard AmEx Discover Cardholder Name Card Number Expiration Date (DD/YY) CVV Number (3 digit number on back of Visa/MasterCard or 4 digits on front of AMEX) Signature: Date:
PLEASE COMPLETE THE INFORMATION BELOW. I authorize The Vista/XXxxxxx’s Kitchen LLC to immediately charge my credit account a date- hold deposit of 50% of the costs associated with my event rental fee. I acknowledge date-hold deposits are non-refundable and if my event is within twenty- five (25) days of the submission of this form, I acknowledge The Vista and XXxxxxx’s Kitchen LLC will be executing withdrawal of 100% of the costs associated with the venue booking. This payment is for my event on 20 . The space rental fees balance will also be charged to this card thirty (30) days prior to your event. Catering, equipment, furniture, and miscellaneous costs will be charged ten (10) days prior to your event. Any additional costs that arise after that date will be charged within two (2) days of your event. Check here if you would like to use an alternative payment method (check, additional credit card, cash, Venmo, CashApp) for the space rental fees balance, bar costs, catering, equipment, furniture, and/or miscellaneous costs. Your CashApp profile _$ Your Venmo profile _@ Please note that if you choose to use an alternative form of payment, payment timeframe remains the same. If the alternative method of payment has not been received by the due date the original credit card will be charged. Billing Address: Billing Phone: City, State, Zip: Email: Signature: Date: Account Type: Visa MasterCard AmEx Discover Cardholder Name Account Number Expiration Date (DD/YY) CVV Number (3 digit number on back of Visa/MasterCard or 4 digits on front of AMEX) I authorize The Vista (SHOPPER’S KITCHEN LLC) to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the event described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. Contact/Renter Initials: Date:
PLEASE COMPLETE THE INFORMATION BELOW. I currently do not have direct deposit for my payroll check and request reimbursements be deposited into the following account. Please complete the information below. Bank Name: Account Number: □ Checking or □ Savings ABA Check Routing Number: Please read, sign, and date below. I hereby authorize the Bethel School District to make reimbursement deposits into my bank account, as indicated above. This authority is to remain in full force and effect during my employment with the Bethel School District until rescinded in writing. Authorizing Employee Signature Printed Name Date Employee’s Home Address Phone # Please mail this form to Bethel School District, Attn: Purchasing Dept., 000 000xx Xxxxxx Xxxx, Xxxxxxxx, XX 00000. You may also submit via email to xxxxxxxx@xxxxxxxx.xxx or fax to 000-000-0000 Attn: Purchasing Dept.
