Credit/ Debit Payment Authorization Form

Schedule your payment to be automatically deducted from your bank account, or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get started!

Here’s How Payments Work:

You authorize charges to your checking/savings account or credit card for services rendered to be made as soon as the day of service, or, by the end of the month in which the service is rendered. A paid invoice for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amounts falls outside of those stated above, in which case you will receive notice from us prior to the payment being collected with a request that you authorize the charge allowing the differences.

Please complete the information below:

I authorize Ren Xue Center for Whole Life, DBA Uplift Yourself, to charge my credit card indicated below for services rendered for the agreed upon price, and on the day of each service, or by the end of the month in which said service is rendered.

First Name

Last Name

Billing Street Address

City

State

Zipcode

US Phone

- -

Credit Card or Debit Card Information

We use the mindbody system for our billing. Please enter your payment details directly there:

Here is how:

1) Click here to get to the mindbody site:

2) Log in

3) Go to the ‘my info’ tab , then PROFILE and click on EDIT for the Billing information. There you can

enter the credit card information.

Signature

Draw It
Clear

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Ren Xue Center for Whole Life in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next service 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. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.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 Ren Xue Center for Whole Life may at its discretion attempt to process the charge again within 30 days, and agree to an additional $40.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

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Credit/ Debit Payment Authorization Form