I authorize MESIVTA OF NORTH JERSEY to debit the bank account indicated in this web form for the noted
amount on the schedule indicated. I understand that this authorization will remain in effect until the
schedule end date, or until I cancel it in writing, which ever comes first, and I agree to notify the
business in writing of any changes in my account information or termination of this authorization at
least 15 days prior to the next billing date. If the above noted payment date falls 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because this is an electronic transaction, these funds may be withdrawn from my account each
period as soon as the above noted transaction date. In the case of an ACH Transaction being rejected
for Non Sufficient Funds (NSF) I understand that the business may at its discretion attempt to process
the charge again within 30 days, and agree to an additional $25 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 will not dispute MESIVTA OF NORTH JERSEY’s recurring billing with my bank so long
as the transaction corresponds to the terms indicated in this agreement.
