Payment Authorization Form

PLESE CONTACT YOUR CUSTOMER SERVICE REPRESENTATIVE PRIOR TO COMPLETING THIS AUTHORIZATION FORM

I authorize Oliphant USA, LLC to charge my bank account with the first payment and subsequent payments, at the amounts indicated, as further provided below.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Oliphant USA, LLC in writing of any changes in my account information or termination of this authorization at least ten (10) days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.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 acknowledge that the Origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

First Payment Date *

Next Payment Date

Frequency

Weekly

Bi-weekly

Monthly

Amount *

Account Type

Checking

Savings

Name(s) on Account *

Bank Name *

Bank City/State *

Account Number (last 4 digits) *

Phone Number *

Email Address *

Street Address *

City *

State *

ZIP Code *

Electronic Communications Delivery Policy This policy describes how Oliphant USA LLC delivers communications to you electronically. We may amend this policy at any time by posting a revised version on this website. You agree and consent to receive electronically certain communications, notices and disclosures (collectively, “Communications”) that we provide in connection with your Oliphant account (“Account”). We will provide these Communications to you via this website.

Hardware and Software Requirements In order to access and retain electronic Communications, you will need a computer with an internet connection, and an installed printer if you wish to print them. In order to download and view your documents on your computer, you need to have Adobe Acrobat Reader installed on your computer. You can download Adobe Acrobat Reader here. We will notify you if there are any material changes to the hardware or software needed to receive electronic Communications from Oliphant by posting them to this website. By giving your consent you are confirming that you have access to the necessary requirement and are able to receive, open, print (if desired) a copy of any Communications for your records. You may print or save a copy of these Communications for your records as they may not be accessible online at a later date.

How to Withdraw Your Consent You may withdraw your consent to receive Communications electronically by contacting us at 1-888-905-1802. If you fail to provide or if you withdraw your consent to receive Communications electronically, Oliphant reserves the right to deny your access to this website.

Requesting Paper copies of Electronic Communications If, after you consent to receive Communications electronically, you would like a paper copy of a Communication we previously sent you, you may request a copy within 180 days of the date we provided the Communication to you by contacting us at 1-888-905-1802. We will send your paper copy to you by U.S. mail to the address we have on file.

Updating your Contact Information It is your responsibility to keep your primary email address up to date so that Oliphant can communicate with you electronically. You understand and agree that if Oliphant sends you an electronic Communication but you do not receive it because your primary email address on file is incorrect, out of date, blocked by your service provider, or you are otherwise unable to receive electronic Communications, Oliphant will be deemed to have provided the Communication to you. Please note that if you use a spam filter that blocks or re-routes emails from senders not listed in your email address book, you must add [email protected] to your email address book so that you will be able to receive the Communications we send to you. You may update your email address by calling us at 1-888-905-1802.

I UNDERSTAND THAT CHECKING THIS BOX CONSTITUTES A LEGAL SIGNATURE CONFIRMING THAT I ACKNOWLEDGE AND WARRANT THE TRUTHFULNESS OF THE INFORMATION PROVIDED IN THIS DOCUMENT. *

Electronic Signature Acknowledgement I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Oliphant USA, LLC in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, 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 acknowledge that the Origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

By signing this Electronic Signature Acknowledgement Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Please call or email with any questions you may have.

I UNDERSTAND THAT CHECKING THIS BOX CONSTITUTES A LEGAL SIGNATURE CONFIRMING THAT I ACKNOWLEDGE AND WARRANT THE TRUTHFULNESS OF THE INFORMATION PROVIDED IN THIS DOCUMENT. *

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