Payment Authorization Form "*" indicates required fields Resident First Name* Resident Last Name* Facility* HiddenType AmountPayment Method* Credit Card ACH HiddenContact ID HiddenState Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name ACH* Account Number SelectSavingsChecking Account Type Routing Number Account Holder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Day of Month to Debit1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15th16th17th18th19th20th21th22nd23rd24th25thConsent for Payment Authorization* I consentI authorize National Preventive Solutions Inc., to charge my account, the monthly premium of for dental service. I agree to notify of any changes to my account information or termination of this authorization at least 5 days prior to the next billing date. I understand that this authorization will remain in effect until I cancel it in writing. I certify that I am an authorized user of this account and will not dispute transactions with my bank; so long as the transactions correspond to the terms indicated herein. I acknowledge that the charge/withdrawal will be processed on the 1st of each month unless otherwise agreed upon.$1 Auth CC Price: $0.50 Auth ACH Price: RecurSignature
