Payment Authorization Form

I authorize Victor E. Castro Dental Studio / Studio-280 to charge my credit/debit card indicated below for my monthly statement amount on the 3rd day of each month for payment of my dental laboratory services.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Victor E. Castro Dental Studio / Studio-280 in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. 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; as long as the transactions correspond to the terms indicated in this authorization form.