Auto Pay Agreement Credit card monthly auto pay or auto charge agreement. Cardholder Name ( as it appears on card)* First Middle Last Billing Address ZIP Code* ZIP Code Card Type - Choose One*VisaMastercardAmerican ExpressDiscoverLast 4 digits* Please only list the last four digits of your card. This is for confirmation purpose - that we are using the correct card.Expiration Date* MM slash DD slash YYYY Name of Person Signing* First Middle Last Consent to charge your credit card monthly.* I agree to the terms and conditions of this Auto Pay AgreementFor your monthly invoices, we bill the card on or about the 1st of the month. By checking the "I Agree to the terms and conditions of this Auto Pay Agreement" box and signing below, you agree to the following terms and conditions: I authorize Rogue Equine Hospital, Inc. to charge the credit/debit card or bank account listed above and for the issuer or financial institution to pay all amounts due Tenant Data for services or otherwise per this authorization. I understand that this authorization will remain in effect until I cancel it in writing or as indicated below (End Date), and I agree to notify Rogue Equine Hospital, Inc. in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this credit/debit card and/or bank account and will not dispute these scheduled transactions with my financial institution or issuer, so long as the transactions correspond to the terms indicated in this authorization form. If I dispute a legitimate obligation owed to Rogue Equine Hospital, Inc., I acknowledged I will be charged and agree to pay a chargeback fee of $15.00 per transaction, which will be initiated as a separate transaction from the authorized recurring payments. I acknowledge and agree that if any amount that I owe Rogue Equine Hospital, Inc. is unpaid after 30 days from invoice date or is referred to collection, I shall pay all of Rogue Equine Hospital, Inc.'s reasonable collection costs, including attorney fees, and court costs. Signature of Person Signing*User finger for tablets or phone, mouse if using a PC/Mac. Date of Signing* MM slash DD slash YYYY CAPTCHA Δ