By providing your electronic signature on this form, you authorize charges to your credit card through [Wix] for services rendered. These charges will appear on your bank/credit card statement as “[Optitude?]” and you will be auto-billed on or before the [5 th/rd/st] of each month for your registration in the Growth Academy. You have the right to request a paper copy of this document.

I authorize Optitude, LLC to charge my credit card each month through [Wix].

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Optitude, LLC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card 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.

 

Print or Type Name:________________________________

 

Signature:________________________________________

 

Date:____________________________________________