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APPLETON PLASTIC SURGERY
5605 Waterford Lane, Appleton
Wisconsin, 54913.

$

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0000 0000 0000 0000 cardholder name expiration card number 01/23 VALID THRU
985 CVV/CID John Doe

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Acknowledgment

The customer hereby authorizes APPLETON PLASTIC SURGERY to debit their bank account for all funds due to APPLETON PLASTIC SURGERY, without regard to the source of such funds in the account. With respect to Automated Clearing House (ACH) settlement of transactions (i.e., electronic debits and credits to and from the customer's bank account), the customer hereby agrees to be bound by the terms of the operating rules of the National Automated Clearing House Association and authorizes APPLETON PLASTIC SURGERY to initiate ACH debit or credit entries and adjustments to the bank account for all products and/or services provided.

APPLETON PLASTIC SURGERY shall not be liable for any delays in receipt, debit, or disbursement of funds, or errors in account entries caused by third parties including, but not limited to, the Association or the bank. The customer shall not close the account without providing APPLETON PLASTIC SURGERY with written notice of such closure and substitution of another account at least five (5) days prior. The customer shall be solely liable for all fees and costs associated with the account.

If APPLETON PLASTIC SURGERY initiates ACH transactions to the customer's bank accounts, all parties agree to be bound by all terms of the most recently signed ACH agreement. In all cases, the customer shall ultimately be responsible for all funds due.

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