All requested information is required. Upon approval, we will automatically draft for the amount indicated and your total charges will appear on your monthly Bank Statement.
I authorize Independent Photo Imagers (IPI) to debit my account as identified above according to the terms stated here. This authorization shall remain in effect until IPI receives written notification from me of any intent to terminate this payment plan and at such time and in such manner as to afford IPI reasonable opportunity to act (min 30 days).
I authorize this plan to continue as long as the payment amount remains unchanged until the plan is terminated by me. I understand any added amounts can be applied for with a new authorization form.
All other changes such as payment amount, frequency, and bank account or credit card numbers, will require a new Electronic Payment Authorization Form to be filled out and submitted via https://form.jotform.com/90435257822155 15 days prior to any change being implemented. I understand that this payment plan may be canceled by IPI, due to Non-Sufficient Funds (NSF). I understand that I will be liable to pay the NSF fees that will be charged by my bank. In the event that IPI is charged an NSF fee by the bank or a revoke authorization fee, I understand that I will be liable to pay these fees and authorize IPI to debit my account for these amounts.
I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this electronic payment plan. I indemnify and hold IPI, the bank, and IPI Merchant Services provider, harmless from damage, loss, or claim resulting from all authorized actions hereunder.