Recurring Charge

You authorize regularly scheduled charges to your Credit Card or Bank Account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your Credit Card or Bank Account Statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. By filling in the information below I electronically authorize Silver Springs at East Norriton to charge my Credit Card or Bank Account below for the amount displayed starting from the date chosen.

Yes

No

Name *

First Name

Last Name

As well as additional ancillary services that I choose to enroll in beginning on

MM

DD

YYYY

One (1) Time Charge

You authorize the merchant below to make a one-time charge to your Credit Card or Bank Account listed below. By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Yes

No

I authorize Silver Springs at East Norriton to charge my Credit Card or Bank Account indicated below

First Name

Last Name

As well as additional ancillary services that I choose to enroll in beginning on:

MM

DD

YYYY

Billing Name *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing Phone *

(###)

###

####

CREDIT CARD INFORMATION

Choose One

Visa

MasterCard

AMEX

Discover

Cardholder's Name

First Name

Last Name

Bank (ACH) Information

(choose one)

Savings Account

Checking Account

Name on Account

First Name

Last Name