Easy Pay Consent Form printable pdf download

Easy Pay Consent Form

I understand and agree to authorize Practice Management Institute® (PMI) to maintain my

credit, debit or check card on file for the balance charges to be paid according to the following

payment agreement:

Program/Course Name:

Program #:

Program/Course Fee:

Discounts (if applicable):

Taxes (if applicable):

S/H Fee (if applicable):

TOTAL FEE:

I agree to pay the above program/course purchase fees. I understand that I must pay 50% of the

course fee at least ten (10) business days before the course begins and the final payment at least

ten (10) business days prior to the course conclusion. I am aware that I will be allowed to make

a total of three (3) consecutive payments within a 90 day period; furthermore, I give my consent

to PMI to charge/debit my credit card, debit or check card on said dates until the balance is paid

in FULL as follows:

payment of $

__ (50% Total Fee) will be made on

____ (Date)

payment of $

__ (25% Total Fee) will be made on

__ (Date)

payment of $ __

(25% Total Fee) will be made on _

__ (Date)

Please have funds available as agreed. You will be held liable for returned payment fees

incurred and processing time.

I understand that this form is valid for one year unless I cancel the authorization through written

notice and make other payment arrangements to have the balance paid in full. I understand that I

am liable and will be held responsible for the FULL payment of my purchase and all means of

collection will be used. By signing this form I agree to the Terms and Conditions underlined

herein.

Course Registrant Name

PMI Invoice

Signature

Date

NOTE: All pages of this form must be completed in full and signed prior to Program/Course

commencing. Payment dates and arrangements must be first approved by the PMI Accounting

Department. All applicable cancellation policies will be enforced during the term of this

agreement.

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Easy Pay Consent Form