Please complete the Payment Authorization Form and submit.
NOTE: The URL above for this form must contain the “s” in https:// at the beginning, otherwise the form/information may not be secure.
You hereby authorize regularly scheduled charges to your Credit or Debit Card or Checking/Savings account. You will be charged the amount indicated as per your Agreement each weekly billing period. You agree that no prior notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 7 days prior to the payment being collected. This form may also be used for One-Time Payments of Set-Up Fees and/or Deposits.
I authorize Topz Salon, Inc. d/b/a Salon Studios to charge my Credit or Debit Card or Checking or Savings account as indicated below for my initial start-up payment and/or on Friday of each week for payment of my Weekly Studio Rent during the duration of the term of my agreement with Topz Salon, Inc. d/b/a Salon Studios.
Please add your full name as it appears on your card or bank account
Address associated with your card or bank account
Number associated with your card or bank account
Please add complete city, state and zip
Email address associated with your card or bank account
Please choose only one payment type
If you chose Credit or Debit Card as your payment type, please complete all fields in this section; the Bank Details section will be disabled as you complete this section.
Security code on back
If you chose Bank Account as your payment type, please complete all fields in this section; the Credit Card Details section will be disabled as you complete this section.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Topz Salon, Inc. d/b/a Salon Studios in writing of any changes in my account information or Termination of this authorization at least 5 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Topz Salon Inc. may at its discretion attempt to process the charge again within 1 day and agree to an additional $35 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment and an additional $25 late fee. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Typing your name here will suffice as your legal signature for the purposes of this authorization.