You authorize regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be mailed to you and the charge will appear on your bank 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. Please fill out and fax back to 631-286-5549 or e-mail to [email protected]

Card Holder Information/Billing Address

Name:

Street

City

State

Zip Code

Phone

Email

Type of Card Being Used:

Credit Card Number:

Expiration Date:

CVC Security Code:

Amount

Ship to: (if different than billing address)

Company Name:

Owners Name:

Street

City

State

Zip Code

By submitted this form I authorize UNeedAPart Inc. to automatically charge my credit card for the amount specified in this form at the beginning of each month for the UneedAPart monthly subscription of the Company listed above. I understand that this authorization will remain in effect until I cancel it in writing by e-mail, and I agree to notify UNeedAPart in e-mail AND by phone of any changes in my account information or termination of this authorization at least 30 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. I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.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 a transaction being rejected for Non-Sufficient Funds (NSF) I understand that UNeedAPart may at its discretion attempt to process the charge again throughout the day, if transaction is still rejected UNeedAPart is authorized to freeze your service until payment is received. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

Cardholder's Signature

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