<AGREEMENT DATE>
Between: <CLIENTNAME> and <STUDIONAME> for [INSERT SERVICE PROVIDED HERE IN EXCHANGE FOR MONTHLY FEE].
Contract Start Date: <CONTRACTSTARTDATE>
Contract End Date: <CONTRACTENDDATE>
Contract Duration and Automatic Renewal: Contract is in force for <NUMBEROFPAYMENTS> months from the Contract Start Date, with automatic renewal for subsequent months, unless cancelled by either <CLIENTNAME> or <STUDIONAME>, with notification of 30 days in advance of the next billing date.
Agreement to Pay Recurring Fees: <CLIENTNAME> agrees to pay <STUDIONAME> monthly recurring fees as follows:
<AUTOPAYITEM> for <AUTOPAYAMOUNT>
via Client authorized automatic credit card or checking account ACH charges. Alternatively, Client may prepay six or twelve months in advance via any credit card, ACH, bank check or wire transfer. Payment in monthly increments by any means other than Client's credit card or ACH is not permitted.
Please read and sign below.
(a) I agree to purchase the <AUTOPAYITEM> for <AUTOPAYAMOUNT>, as an automatic charge to my credit card, or automatic debit to my checking account each month for a contract period of <NUMBEROFPAYMENTS> months.
(b) I hereby certify that I am the holder of the credit card, or an authorized signer on the bank checking account detailed below.
(c) I understand that I will be notified if my credit card or checking account payment fails to authorize for any reason, and that a $10 late fee will apply if I do not provide a valid credit card or checking account ACH information within 10 calendar days of the original rejection date.
(d) I understand that my service will be deactivated if my account becomes more than 30 calendar days late.
Signature: _______________________________________Date: ____________
Printed Name: ____________________________________
CHARGE THE FOLLOWING CARD OR BANK ACCOUNT EACH MONTH:
Cardholder Name: ________________________________________________
Credit Card Number: ______________________________________________
Expiration Date: ________________
Signature of Cardholder: ___________________________________________
--OR--
BANK NAME: _____________________________________________________
NAME ON ACCOUNT: ______________________________________________
AUTHORIZED SIGNER NAME: ________________________________________
SIGNATURE OF ABOVE: ____________________________________________
RTN NUMBER: ___________________________________________________
ACCOUNT NUMBER: ______________________________________________
Freeze your Auto Pay
To freeze your auto pay, a completed request must be submitted in writing at least 30 days in advance of your next billing date in order for your request to be effective from the following month. Billing date is based on your activation date listed below.
Clients enrolled in the monthly auto renew program may elect to freeze their auto pay charges once per year according to the policy below:
You can freeze your Auto Pay schedule once per year at any time for a fee of $15 per month. The freeze is activated at the start of the next billing cycle and can be requested in monthly increments for up to 6 months.
To request the freeze, complete a freeze request form at the front desk and submit it via fax or in person to the front desk.
Following the end of your requested freeze period, your monthly auto-renew will automatically be reactivated.
Cancel your auto pay
Your auto pay schedule may be canceled at any time.
A completed auto pay cancellation form must be received at least 30 days in advance of your billing cycle (example: if you are scheduled to be charged February 14th and you want to cancel for the month of February, you must submit a cancellation form to <STUDIONAME> by January 14th.)