Fill and Sign the Payment Agreement Form

Installment Payment and Purchase Agreement Bill to: ___________________________________________________________________ (Name, street address or post office box, city, state, zip code)Ship to: __________________________________________________________________ (Name, street address or post office box, city, state, zip code)Phone Number of Buyer: _______________________ E-Mail ______________________Driver’s License of Buyer: __________________ State: __________ Date of birth: ______Referred by: _________________________________________________ DOWN PAYMENT Product AmountNumber of units Total Initials ___________________ $________________________ ___________________(Name of Product)___________________ $________________________ ___________________(Name of Product)___________________ $________________________ ___________________(Name of Product)___________________ $________________________ ___________________(Name of Product)Shipping and Handling $__________TOTAL DOWN PAYMENT $ ________________I AUTHORIZE THIS AMOUNT TO BE CHARGED TO MY CREDIT CARD. INTIAL HERE________ MONTHLY PAYMENTS Number of Monthly AmountNumber of Units Total InitialsPayments Per Unit_________ $________________________ ___________________________ $________________________ ___________________________ $________________________ ___________________________ $________________________ ___________________________ $________________________ __________________ TOTAL MONTHLY CHARGE $_________________I AUTHORIZE THIS AMOUNT TO BE CHARGED TO MY CREDIT CARD. INTIAL HERE________ Payment Information (Check one of the following:)Visa [ ] Credit card #________________ Expiration Date ___________MasterCard [ ] Credit card #________________ Expiration Date ___________Discover [ ] Credit card #________________ Expiration Date ___________American [ ]Credit card #_____________ Expiration Date ___________Express Payment Agreement This Installment Payment Agreement (the Installment Agreement) is entered into between _________________________ (Name of Seller), a corporation organized and existing under the laws of the state of ______________, with its principal office located at ___________ ____________________________________________________________________________ (street address, city, state, zip code), referred to herein Seller, and the company or individual identified below as Buyer below, referred to herein as Buyer .This Installment Agreement is subject to the approval by Seller and relates to the sale of Equipment identified by the serial numbers listed below. This Installment Agreement is noteffective until signed by Seller. Buyer understands the Equipment sold under this InstallmentAgreement shall remain the property of Seller until all required payments have been paid in full.Possession and ownership of the Equipment may not be transferred by Buyer until all paymentsare paid in full and Buyer has received written acknowledgment that all payments have beenreceived by Seller. If the Equipment is transferred prior to Seller’s receipt of all payments, nowarranty claims relating to the Equipment will be honored. Seller will refund the purchase priceon any Equipment returned to Seller in its original condition and in its original packaging within30days of the date of purchase, less a restocking fee up to $_________ at the sole discretion of Seller. If the Equipment is damaged or is missing accessories, an additional refurbishment fee up to $___________ may also be charged at the sole discretion of Seller. In the event theEquipment is returned under this policy, Seller will use its best efforts to cancel the remainingautomatic payments scheduled for billing. However, if payments are processed after the returnof the Equipment, Seller will refund the total amount paid, subject to the restocking and refurbishment fee within 30 days of receiving equipment. The Equipment is protected by the Limited Warranty stated in the Operations Manual. All warranty claims and issues must follow procedures in the Operations Manual. The failure of an automatic payment shall constitute an event of default by Buyer and Buyer shall have a 10 day right to cure period following written notice by Seller of such default. In the event this Installment Agreement is referred to an attorney for collections, Buyer will be liable for reasonable and necessary attorney’s fees and costs of collection.Witness our signatures this the _____ day of ______________, 20_____. _________________________(Name of Seller) ________________________ By:______________________________ (Printed Name of Buyer) __________________________________________________ (Printed name & Office in Corporation) (Signature of Buyer) ___________________________ (Signature of Officer)