EFTA00313919.pdf

Credit Card Payment Authorization Patient's Name: Credit Card: Visa Mastercard Discover AMEX y_ Card Number:_l Expiration Date: Security Code: q049 Name as it appears on credit card: TG t Reat•--i Epa--fu l(•.1 Billing Address for card: eAST- IQ`f, fQ`I )000-\ "PA`tii\li4 P0te 0-1- 12N4/4(-1 T4NI. 1-4S018.1 the above named account h• authorize $ to be charged monthly to my credit card on th business day of each month for orth tic services rendered in accordance with • contract with MJR Dental Services LLC. The first charg *II occur on ereby acknowledge that the amount withdrawn in any given mo • may vary shou her charges be incurred, but in no event will the amount to be withdrawn ex -d t current amount due. Once the automatic charge is activated, transa will occur on the l business day of every month until my account is pa full. I understand if the payment is declined for any reason, a $39.00 fee will b- plied to the account, and I wi mptly remit the total monthly payment due. If ment is no received by the last business of the month, a $50.00 late fee will pplied to the account. I may cancel this authorization by notifying Dr. Jeffrey Rappa in writing 30 days before the scheduled • ayment is due. Date: JAN. Th Signature of account holder: EFTA00313919