This FORM is REQUIRED if you would like to set up Payment Plan. Please Fill this FORM in its Entirety choosing your mode of payments and then Submit. Thank You
Please Enter Your First Name
Please Enter Your Last Name
Please Enter Your Date of Birth
Your Consent To Make Automatic Monthly Payments
I give ALI MEDICAL, LLC permission to take funds out of my bank account / my credit/debit card to pay towards my BALANCE DUE on monthly basis till NO BALANCE DUE is left payable to ALI MEDICAL, LLC.
Type Your Name
By Typing My Name In This Box, I Agree To The Contents And Conditions As Listed In This Agreement Form.
Date Of Signature
Please Enter Amount you would like to pay every month.
Information About Your Bank
Please provide information about your Bank if you would like to make Monthly Payments through your bank account, otherwise go to the Credit / Debit Card Section Below:
Please Enter Name Of Your Bank
Please Enter Name On the Bank Account
Please Enter Bank Routing Number
Please Choose From the Dropdown Menu
Please Enter Your Bank Account Number
Credit / Debit Card
Please Provide Information about your Credit / Debit Card if you would like to make Monthly Payments using your Credit / Debit Card. Thank you.
Please Enter Your Credit / Debit Card Number
Please Enter Name on Credit / Debit Card
Please Enter Expiry Date of Credit / Debit Card: mm/yyyy
Please Enter Three Digit Security Code
Billing Address:
Please Enter Street Address
Please Enter City
Please Enter STATE
Please Enter ZIP Code
