Payment Authorization Form

I, {Name (First):6.3} {Name (Last):6.6}, authorize Wienhoff Drug Testing, Inc to charge my {Payment Type:15:value} for {Billing Amount:11}, on the {Billing Day of Month:39} of each month.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Wienhoff Testing, Inc in writing of any changes in my account information or termination of this authorization at least 5 days prior to the next billing date. If the above-noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the merchant may at its discretion attempt to process the charge again within 30 days, and agree to an additional $ 25 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.