Card Number. Exp. Date: ……....… CVC: ........... Cardholder: ………………………………………… Cardholder’s Signature: ……...….......…….…….……...…………. Card Billing Address: …………….…………………………………………………………………………………………………………........…..…. (if different from above) (Street) (City) (State) (Zip) 🞏 Please also charge above credit/debit card with the remainder of my balance/s as due. or 🞏 I agree to pay the balance/s as due by (please check one): 🞏 mailing a check 🞏 calling w/a credit card 🞏 paying in person. I HAVE COMPLETED THIS FORM TO THE BEST OF MY KNOWLEDGE AND STATE THAT THE INFORMATION GIVEN IS TRUE AND CORRECT. I FULLY UNDERSTAND, AGREE TO, AND WILL ABIDE BY THE REGULATIONS AND POLICIES STATED WITH THIS FORM, THE STUDENT HANDBOOK, AND SCHOOL POLICIES. MY SIGNATURE BELOW CERTIFIES THAT I HAVE READ, UNDERSTOOD AND AGREED TO MY RIGHTS AND RESPONSIBILITES AS STATED WITH THOSE DOCUMENTS AND THIS FROM. Student’s Signature Date ACCEPTED BY:
Card Number. Name on Card: ........................................................................................
Card Number. CVN: ..........................................................................................................................
Card Number. Expir. Date: CCV Number: Zip Code w/ Card:
Card Number. The 16 digit number on the front of your Card.
Card Number. Expiry date :.............................................................................................................................. CVC: .........................................................................................................................................
Card Number. Exp. Date: / Electronic Debit/Auto Check(Your accountwillbedebitedoncemonthly) Account Type Checking Savings General Ledger Loan Customer Type: Business Consumer Bank Name: Routing Number: (9 digits) Account Number: *CHECK ALL SERVICES YOU WISH TO INCLUDE WITH YOUR SUBSCRIPTION* Administrative Contact (This person will have access to online billing reports as well as have the authority to add/removeusers from theaccount): Name E-Mail Phone OFFICE USE ONLY Admin Username: Signatureof Agreement I have read and I agree to the terms and conditions of the Access Idaho Premium Subscription Agreement. Signature Name (printed) Title Date AGREEMENT FOR IDAHO DLR, MVR & DASHBOARD RECORD PROCESSING This agreement is made between , a corporation with its principal office in (hereinafter “SUBSCRIBER”), and Idaho Information Consortium, Inc., doing business as Access Idaho, and portal manager of the State of Idaho’s initiative known as Access Idaho (hereinafter “Access Idaho”).
Card Number. Expiration Date Security Code Cardholder Signature Booth Pricing Member Rates Non-Member Rates Field 10 x 10 $705 $880 Field 10 x 10 corner $775 $970 Field 10 x 20 $1,390 $1,740 Field 10 x 30 $2,060 $2,575 Field 20 x 20 $2,710 $3,390 Concourse 8 x 10 $535 $665 Concourse 8 x 20 $1,055 $1,315 Lobby 8 x 10 $565 $710 *for additional sizes and rates contact Xxxxxxx Xxxxxxx at xxxxxxxx@xxxxx.xxx. Cardholder Billing Address Exhibitor Checklist: □ Signed Contract □ Certificate of Liability Insurance □ Payment Exhibitor Authorized Signature Date Home Builders Association of Fargo-Moorhead Date Exhibitor acknowledges having read this Contract, which includes the Standard Terms and Rules & Regulations on Pages 2 and 3. Contract will not be accepted without payment and a certificate of liability insurance that meets the requirements identified on Page 2. STANDARD TERMS
Card Number. Expiry: ........./......... STEP 5: AUTHORISATION Your signature indicates you authorise Friends of Trinity Trust (User ID number 079475), until further notice in writing, to debit your nominated bank account or credit card as per the giving options and schedules in Step 3 of this form. It also indicates that you have read and understood the Direct Debit Request Service Agreement on the back page of this document. It also indicates that you are prepared to pay any dishonour fees if there are insufficient funds in your account. Note: If you have a joint account, all signatures may be rquired) Signature: ................................................................................ Date: ................................................. Signature: ................................................................................ Date: ................................................. Please return this form to by popping it in the collection bags on a Sunday or by mailing to: PRIVATE AND CONFIDENTIAL Friends of Trinity Trust - Trinity Inner South 000 Xxxxxx Xxxxxx
