Payment Plan Form

PAYMENT PLAN AUTHORIZATION

In consideration for the program fee of $_________ (total, type in below), I agree to pay for the instruction provided by Dr. Jill Wener and authorize Dr. Wener to deduct the following amounts in accordance with the payment schedule as follows, from the account listed below:

Please Enter Total Amount

Down Payment Information

Down Payment Date

YYYY

Amount To Be Paid

enter down payment amount

Recurring Payment Information

Amount To Be Paid

enter amount per payment

Every _____ days/weeks/months

enter number and interval

Date of First Payment

YYYY

Date of Last Payment

YYYY

Payments will be made by

select all that apply

Cash or check

Chase Quickpay, Venmo, or Google Wallet

Credit card (a 3% service fee applies, you will receive an invoice for each payment)

It is understood that if the student misses payments, without prior notification and agreement, Dr. Wener reserves the right to transfer collections to a collection agency.

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Electronic Signature

First Name

Last Name

Today's Date

YYYY

Conscious Health Meditation + Wellness 127 Clay St SE Atlanta, GA 30317 773.573.8197 Jill@JillWener.com (Venmo, Google Wallet, Paypal) JillWener@gmail.com (Chase Quickpay) www.JillWener.com