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Payment Plan Form - Astron by huangyuarong

VIEWS: 8 PAGES: 2

									                                                                          MONTHLY PAYMENT PLAN APPLICATION
ID NO.                                  NAME:

ADDRESS:                                                           PHONE #:

                                                                       E-MAIL:

I Agree to pay all charges with a 6 Month Plan                         For Services Rendered:
                                                 initial
DISCLOSURES:                                     ***DUE DATE: PP/CK/CH *CHARGES:                FEE **DATE       PAID INT
        1              TOTAL CHARGES                                    $     -
        2              20% OF DUE BILL                                  $     -
        3              1ST PAYMENT                                      $     -
        4              2ND PAYMENT                                      $     -
        5              3RD PAYMENT                                      $     -
        6              4TH PAYMENT                                      $     -
        7              5TH PAYMENT                                      $     -
        8              6TH PAYMENT                                      $     -

PROMISSORY NOTE:
For and in consideration of the above application, and subject to all the provisions thereof, I hereby promise to pay
ASTRON BUSINESS & TAX SERVICES, LLC, of Accounting and Administration Management the sum of $ $                               -
and any additional charges add to this agreement as stated and disclosed above. I am aware that this contract is legal
and binding upon me. I acknowledge that I have received a copy of this agreement. I have read and agreed to ALL
information this payment plan has set forth herein. I understand that if I submitt any credit/debit card information on this
form it will be charged on the due date with no hesitation. I understand a $15.00 fee will be added every week for late payment.

CLIENT SIGNATURE                                                                  DATE



SPOUSE SIGNATURE                                                                  DATE



TONI WOODS-FULLER, V.P ADMINISTRATION                                             DATE

EXTENSIONS (OFFICE USE ONLY)                     $5.00 ADDITIONAL FEE
EXTEND #               PAYMENT OF            $                           TO:                    ADMINISTRATION INT.

                          TYPES OF PAYMENT WE ACCEPT
~CREDIT/DEBIT CARD                          ~MONEY ORDERS                                                  ~REFERRAL REFUNDS
~CHECKS ($30.00 NSF CHARGE)                 ~PAY PAL                                                   ~POST DATED PAY
                                       ****If paying by credit card complete below:

CARD TYPE:                                                         BILLING ADDRESS:
MONTHLY PAYMENT $                                                  CITY, STATE, ZIP:
CARD NUMBER:                                                       CARDHOLDER NAME:
SEND RECEIPT?                   YES                           NO
Exp. Date:                                       CVA Code                                       SIGNATURE
*Change amount according to your amount due.

** Any additional amount you want to pay extra.

*** Usually on issue for 1st, 15th, and 30th. However
those who would like biweekly add dates.

**** Should be filled out completely for all automatic
withdrawls.

								
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