EmailMe Form - Services Order / Payment Authorization Form

Company Name *
Name *
First Last
Title / Position *
Phone *
### - ### - ####
Email *
Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Company Address if not the same as billing address.

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Form of Payment *
Amex
Mastercard
Visa
Credit Card *

Card Number

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Name as it appears on the card: *
The above authorizes The NTR Group, LLC to use the herein referenced Credit Card Account for any and all invoices associated with services provided to this client. Payment is processed at time of agreement or otherwise as outlined.
Additional Terms: Please type initials to indicate you have read and agree to the terms herein. *
Additional Terms
I hereby authorize The NTR Group, LLC to charge my credit card or bank account in the amount and frequency indicated above. I further agree to be bound by the terms of my cardholder agreement or my bank account agreement. I understand there will be a $35 fee for any transaction which is declined for any reason by my financial institution. This transaction, and my use of any and all products and services from The NTR Group, LLC is contingent up on my acceptance of their terms and conditions in the authorized Agreement for Services. Finally, I hereby hold The NTR Group, LLC harmless for any and all claims, actions, or loss I may experience, agree to accept training and services as is, and limit The NTR Group, LLC liability to an amount that shall not exceed the service fee listed on invoice or agreement.
Note: An administrative fee of 5% will be added to fees paid via Credit Card.

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