Print This Page. It is the Authorization Form
Subscription Form for ChiroSite.org
NOTE: We CANNOT debit foreign bank accounts. If you are a foreign customer you will have to use the credit card option.
To get started simply print this web page. Then just fill out the form and mail, or fax back to VenturaDesigns at (913) 239-8466. Once the down payment is processed we will e-mail you your Username and Password. Call (913) 239-8465 with any questions, or e-mail sales@posturepro.com .
Recurring Payment Plan for the Subscription to ChiroSite.org
Monthly
Charge/Debit: Nine Dollars
and Ninety Five Cents ($9.95) USD
Number of Monthly Recurring Charges: Unlimited, until cancelled
Credit
Card or Check
RECURRING
CHARGE AUTHORIZATION FORM (Check or Card)
PRINT BLANK FORM and complete with black or blue ink pen before mailing
or faxing. Please PRINT clearly. INCOMPLETE FORMS CANNOT BE PROCESSED. Remember
to fill out ALL INFORMATION.
AUTHORIZATION
Last Name_____________________________First Name ___________________
Billing
Address_______________________________________________________________
CITY___________________________________________________
ZIP Code_________________ State_______Telephone
___________________
Contact Email Address_____________________________________________
Card Number (credit card orders
only)____________________________________________________
Expiration Date_______________
CVM (Card Security ID) number_________
Name of Cardholder______________________________________________________
Paying By Check? Please sign at the bottom and then go to the next page.
This
form must be completed and returned to VenturaDesigns 13913 Flint Overland Park,
KS 66221 PHONE: (913) 239-8465 FAX: (913) 239-8466
, E-Mail: info@posturepro.com
before automatic recurring credit card billing, or check withdrawal can begin. Incomplete forms cannot be processed.
I
hereby authorize VenturaDesigns to charge the indicated credit card, or debit
the assigned bank account the amount listed on page one of this form for
software listed on page one of this form. I agree that this is a periodic charge
that will be made according to my billing cycle, and in order to terminate the
recurring billing process I must arrange for an alternative method of payment. I
agree not to dispute VenturaDesigns's recurring billing with my credit card
issuer, or bank as long as the amount in question was for software purchased
under this agreement.
I
agree that I will not dispute any charges from VenturaDesigns unless I have
already made an effort in good faith to rectify the situation directly with
VenturaDesigns, and those efforts have failed.
I
guarantee and warrant that I am the legal cardholder for this credit card, or
the signator of the bank account listed, and that I am legally authorized to
enter into this recurring billing agreement with VenturaDesigns.
Account Holder/Cardholder's Authorized
Signature________________________________________ Date________________
I/We will inform the
Payee (VenturaDesigns), in writing, of any change in the information provided
in this section of the Authorization prior to the next due date of the
PAYMENT.
2. Payee's Name and Address
|
Name of Payee (the "Payee") VenturaDesigns. |
|
|
Street : 13913 Flint |
|
|
City/State: Overland Park, KS |
|
|
Zip Code : 66221 |
|
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Tel : (913) 239-8465 |
|
3.
I/We
acknowledge that the Authorization is provided for the benefit of the Payee
and the Processing Institution and is provided in consideration of the
Processing Institution agreeing to process debits against my/our account, as
listed above, (the “Account”).
4.
I/We warrant and guarantee that all persons whose signatures are required to
authorize withdrawals from the Account have signed the Authorization below.
5.
I/We hereby authorize
the Payee to issue Pre-Authorized Debits drawn on the Account, for the
following purpose:
Subscription Payment Schedule
Listed on Page One of This Form.
6. I/We acknowledges that provision and delivery of the Authorization to the
Payee constitutes delivery by me/us to the Processing Institution. Any
delivery of the Authorization to the Payee, regardless of the method of
delivery, constitutes delivery by me/us.
7. The debit
is for the amount listed on page one of this form and is to be drawn on the
account Monthly.
8.
Revocation of the
Authorization does not terminate any contract for goods or services that
exists between me/us and the Payee. The Authorization applies only to
the method of payment and does not otherwise have any bearing on the contract
for goods or services exchanged.
9. I/We understands and accept the terms of participating in this plan.
Authorized Signature
Date
*Please Fax
this form or Mail
it (together with your void check) to
VenturaDesigns
13913 Flint
Overland Park, KS
66221
PHONE: (913)
239-8465
FAX: (913) 239-8466
E-Mail: sales@posturepro.com