House Account

The Customer acknowledges responsibility to pay an amount equal to the total of all purchases and charges reflected on the statement, whether incurred by the Customer or by an individual authorized by the Customer above. As designated above, Customer authorizes charging the Customer’s credit card or will pay by Customer check. Charges to a

Customer’s card will be made automatically on the statement date (on the 10 day after the statement date). Check payments must be received by the Center within __ days of the statement date, as indicated above, or the Center will charge the amount due to the Customer’s credit card.

In the event that a charge is rejected or a check is returned for any reason, Customer agrees to make full and prompt payment immediately upon receipt of notice. Customer is responsible for and will reimburse any fees or charges incurred by the Center as a result of a rejected charge or returned check.

Interest at the rate of 1.5% per month will be assessed on the total of any amounts not paid within thirty (30) days of the statement date. The Customer agrees to pay any and all costs, including reasonable attorneys’ fees, incurred by the Center in an attempt to collect any outstanding balances(s). The Center may, in its sole discretion, suspend or cancel any House Account with a balance unpaid more than 30 days after the statement date.

This credit card authorization does not constitute an agreement to provide, nor is it intended to imply the existence of, any extension of credit or any credit options. The Center may, at its discretion, restrict charges on this House Account in general or with respect to any type of products and/or services. The Center may also cancel this agreement at any time for any reason by giving written notice to the Customer, at which time all amounts then outstanding are due and payable immediately.

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Title

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Card To Be Billed MC VISA AMEX DISC

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Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL
Card To Be Billed	MC VISA AMEX DISC
Credit Card#
Security Number
Expiration Date
Billable Zip Code
	Services Are Extended To
Name
Name
Name
Name
Name