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Payment Authorization

Card Holder Name(Required)
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.
Name of Account for Payment Authorization(Required)
What Member are you authorizing payment for?
MM slash DD slash YYYY
Payment Amount(Required)

Payment Authorization(Required)

You authorize regularly scheduled charges to your credit card or bank account. You will be charged the outstanding amount each billing period. You agree that no prior notification will be provided unless the amount changes


I agreed to be fully responsible for the outstanding balance of the above party listed in this agreement within the terms of the contract. This agreement expires 1 year after submission.