Payment Plan Form

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					                                                       AHDI Payment Plan Enrollment Form
                                                       For Individual Professional Members

This form must be submitted along with your completed membership application or renewal notice.

Please note the payment plan is only available for Individual Professional memberships.

                                                                  (     )-
 Name (print or type)                                             Phone

Terms & Conditions:

I authorize AHDI to charge my credit card three (3) payments of $47 each, for a total of $141. The initial
payment will be charged to my credit card at the time of the order placement if I am a new or reinstating
member. As a renewing member, the initial payment will be charged on or around the first day of my new
membership term. The two subsequent payments will be charged on the second and third months of
membership, approximately 30 days apart. I understand that by enrolling in the payment plan my
membership will automatically renew each year, using the same credit card I am enrolling with today. I also
understand I will receive a reminder email approximately three (3) months prior to when my membership is
set to automatically renew. I am responsible for notifying AHDI prior to my membership renewal date if I
wish to discontinue membership or if my credit card information has changed. I understand that it is my
responsibility to maintain up-to-date contact information with AHDI, including email address. I understand
that membership is not refundable or transferable.

                                       Payment:          Visa        Master Card           American Express         Discover
 AHDI Membership is for one year
 from the original join date. AHDI
 dues and benefits are nonrefundable
 and nontransferable.
                                              Credit Card #                                             Exp. date
 AHDI occasionally rents its
 membership list to prescreened
 vendors for direct-mail advertising          Cardholder name (please print)
 related to medical transcription.
 Indicate if you want to have your
 name withheld.                               Authorized Signature                                      Date

   Yes, please withhold my name        I acknowledge that by signing this form, I have read and agree to the terms
                                       & conditions of the AHDI payment plan.

                              4230 KIERNAN AVENUE, SUITE 130, MODESTO, CALIFORNIA 95356
                  PHONE: 800-982-2182  FAX: 209-527-9633  EMAIL:  WEB:

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