Standard Contracts
Payment Authorization AgreementPayment Authorization Agreement • February 13th, 2023
Buyer Seller Dealer #:D1110 Name:ERIC WOLINSKI Name:Everything Breaks Address:645 PAULINE AVE Address:5706 E. Mockingbird Lane, Suite 115-212 City:DEERFIELD, State:NY, Zip:13502 City:Dallas, State:Texas, Zip:75206 Phone #:(315) 723-5476 Phone #:800-895-0842 Email:ecaddieman@gmail.com Salesperson:Everything Breaks Email:support@everythingbreaks.com
ContractPayment Authorization Agreement • October 26th, 2020
The Buyer identified in the payment authorization described below (“Buyer”) agrees to pay the total purchase price for the goods and/or service acquired from the Seller in the amount notified to Underworld Kennels & Dog Training LLC (“UKDT LLC”) by the Seller (“Purchase Price”) and authorized by the Buyer, in either a single payment or in the number of installment payments as set forth in the payment
TERMS AND CONDITIONSPayment Authorization Agreement • December 11th, 2018
Bridlewood Villas HOA Payment Authorization AgreementPayment Authorization Agreement • April 18th, 2012
Payment Authorization AgreementPayment Authorization Agreement • September 4th, 2012
For newly issued policies only: For ease of your policy administration, if the policy is issued, we will make the effective date of coverage the same as your selected draft date following the receipt of your application at Aflac Worldwide Headquarters. For Direct Life only, if the policy is issued, we will make the effective date of coverage the same as your selected draft date following the approval by Underwriting of your application.
PAYMENT AUTHORIZATION FORMPayment Authorization Agreement • September 11th, 2020
For your convenience, we require that membership and program fees be payed via our “Easy Pay” plan, where fees are automatically deducted from a valid checking account, bank debit card, Visa, MasterCard or Discover. This electronic debiting process is an easy and convenient way to pay. Please take a moment to read the terms of the plan and sign below. Feel free to speak with a Member Services Representative if you have any questions. Thank You.
Payment Authorization AgreementPayment Authorization Agreement • July 26th, 2023
This Payment Authorization Agreement is a contract between the STUDENT and Tulsa Tech, and every student is required to sign and return this form to their Campus Bursar (handles student billing and payments) before the first day of class, regardless of whether you receive Financial Aid.
Contact InformationPayment Authorization Agreement • June 17th, 2024
Payment Authorization and AgreementPayment Authorization Agreement • May 19th, 2019
Holiday Harbor Marina Payment Authorization Agreement for Monday Morning ChargesPayment Authorization Agreement • December 15th, 2023
To have CHARGING PRIVILEGES for store purchases, fuel, carry out, marine accessories, service work orders, etc., complete the form below. NOTE: A 3% convenience fee will be added to the total of accrued charges if paid by credit card on file, around the first and 15th of the month. You have the option to pay by check before then, to avoid convenience fees.
ContractPayment Authorization Agreement • October 26th, 2021
I, , in conjunction with the executed Independent Contractor Agreement, do hereby agree to allow eXp Realty LLC, to use the following payment method for my monthly technology fees. I understand the monthly technology fees are one requirement needed to keep my account “In Good Standing”.
MTMnet, Inc.Payment Authorization Agreement • November 24th, 2003
Huron Lagoons Marina Payment Authorization Agreement for Charging PrivilegesPayment Authorization Agreement • March 15th, 2023
To have CHARGING PRIVILEGES for store purchases, fuel, carry out, marine accessories, service work orders, etc., complete the form below.
Parent Name and Surname Cell Number Agreement Ref. Number(Office Use) Email address Bank name Account name Name of Branch Account number Branch Code Account type Cheque/savings/transmission I hereby request, instruct and authorise Bridge House to draw...Payment Authorization Agreement • October 26th, 2021
Holiday Harbor Marina Payment Authorization Agreement for Monday Morning ChargesPayment Authorization Agreement • January 26th, 2023
To have CHARGING PRIVILEGES for store purchases, fuel, carry out, marine accessories, service work orders, etc., complete the form below. NOTE: A 2.5% convenience fee will be added to the total of Monday morning charges.
City of Big SandyPayment Authorization Agreement • June 25th, 2021
ContractPayment Authorization Agreement • January 4th, 2017
PAYMENT AUTHORIZATION AGREEMENTPayment Authorization Agreement • November 5th, 2015
For all new policies except for life insurance, your coverage will be effective as of the date of application if 1) you provide a full monthly premium payment at the time of application or authorize a full monthly premium payment with an Initial Payment date that coincides with the Application Date, 2) you provide a Recurring Payment Start Date no later than 45 days after the Initial Payment Date, and 3) the coverage applied for is issued. Otherwise, your coverage will be effective as of the date it is issued by United Schools Associates and/or its affiliated insurance carries and the effective date will be provided to you as part of your policy documentation.
Copperview Village HOA Payment Authorization AgreementPayment Authorization Agreement • May 15th, 2013
Payment Authorization and AgreementPayment Authorization Agreement • October 31st, 2017
Boston Child Study Center requires all clients to provide a credit or debit card on file to be processed monthly in the amount due on your account. All credit or debit card information is stored in our electronic medical record, which maintains full HIPAA compliance as well as PCI compliance to ensure your personal and financial information is secure, respectively.
Hillcrest HOA Payment Authorization AgreementPayment Authorization Agreement • April 18th, 2012
Agreement to file Credit Card or ACH Bank Account Information and Authorization of Payment (choose either Credit/Debit or ACH Bank Transfer and enter information below)Payment Authorization Agreement • March 5th, 2018
Payment Authorization AgreementPayment Authorization Agreement • April 7th, 2021
This Payment Authorization form will serve as the patient authorization and agreement for all providers within our Practice Management Group: Beyond Wellness LLC, Loudoun Family Chiropractic LLC, Dee Chiropractic PLLC, Natural Health Therapies LLC, Araya Holistic Pain Management LLC, Elite Performance Chiropractic and Wellness LLC and Core Health Chiropractic.
Holiday Harbor Marina Payment Authorization Agreement for Charging PrivilegesPayment Authorization Agreement • July 31st, 2024
To have CHARGING PRIVILEGES for store purchases, fuel, carry out, marine accessories, service work orders, etc., complete the form below.
Whisper Rock HOA Payment Authorization AgreementPayment Authorization Agreement • January 31st, 2022
WELLNESS CENTERPayment Authorization Agreement • February 23rd, 2010
Payment Authorization AgreementPayment Authorization Agreement • June 13th, 2018
Payment Authorization AgreementPayment Authorization Agreement • September 4th, 2012
For newly issued policies only: For ease of your policy administration, if the policy is issued, we will make the effective date of coverage the same as your selected draft date following the receipt of your application in the home office. For Direct Life only, if the policy is issued, we will make the effective date of coverage the same as your selected draft date following the approval by Underwriting of your application.
Last Name First NamePayment Authorization Agreement • May 6th, 2021
Payment Authorization Agreement Automatic Bank Draft I understand that if my bank draft is declined for any reason in a given month, there will be a $30 service fee Member in addition to the monthly membership fee. This must be taken care of by the 20th of said month to avoid Initials termination of membership. If terminated there will be a $25 reinstatement fee. Checking – Copy of Check Required (bank deposit slips DO NOT provide the appropriate data needed for an EFT.)Saving – Please obtain appropriate routing/account data from bank as savings as savings deposit slips DO NOT provide the appropriate data needed for an EFT.Bank Name: Name on Account: Routing Number: Account Number: Member Signature Date / / Debit/Credit Card I understand that there will be an added convenience fee for credit card drafts. Convenience Fee: _ Member If my credit card is declined for any reason in a given month, there will be a $30 service feeInitials in addition to the monthly membership fee. This must be
Westbury HOA Payment Authorization AgreementPayment Authorization Agreement • April 18th, 2012
Policyholder / Applicant InformationPayment Authorization Agreement • January 6th, 2017
same as your selected draft date following the receipt of your application in worldwide headquarters if the policy is issued.
Canyon Glen HOA Payment Authorization AgreementPayment Authorization Agreement • May 15th, 2013
Agreement/ Application form with creditorPayment Authorization Agreement • August 28th, 2009
I/We hereby authorize my/our below-named Bank to effect transfer from my/our account to that of Zurich Insurance Company Limited (name of beneficiary) in accordance with such instructions as my/our Bank may receive from the beneficiary from time to time provided always that the amount of any one such transfer should not exceed the limit indicated below.
ContractPayment Authorization Agreement • December 4th, 2017
Last Name First NamePayment Authorization Agreement • June 5th, 2020
Payment Authorization Agreement Automatic Bank Draft I understand that if my bank draft is declined for any reason in a given month, there will be a $10 service fee Member in addition to the monthly membership fee. This must be taken care of by the 20th of said month to avoid Initials termination of membership. If terminated there will be a $25 reinstatement fee. Checking – Copy of Check Required (bank deposit slips DO NOT provide the appropriate data needed for an EFT.)Saving – Please obtain appropriate routing/account data from bank as savings as savings deposit slips DO NOT provide the appropriate data needed for an EFT.Bank Name: Name on Account: Routing Number: Account Number: Member Signature Date / / Debit/Credit Card I understand that there will be an added convenience fee for credit card drafts. Convenience Fee: _ Member If my credit card is declined for any reason in a given month, there will be a $10 service feeInitials in addition to the monthly membership fee. This must be
