FORM AUTOMATIC WITHDRAWALS

AUTOMATIC WITHDRAWALS

AUTHORIZATION FOR AUTOMATIC WITHDRAWALS

,as the authorized agent of Company, above, hereby authorize PreCheck Health Services, Inc., Secured Party, or its assigns, to initiate, on a monthly basis, debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to our account indicated below and the financial institution named below. I also authorize PreCheck Health Services, Inc., Secured Party, or its assigns, to initiate a one-time debit for the deposit (Applied to Advance Payment(s), Documentation Fee, Site Fee and other fees).
(lower left corner of check, 9 numbers):

This authority is to remain in full force and effect until PreCheck Health Services, Inc., Secured Party, or its assigns has received the full sum ofmonies owed. We understand that our withdrawal of this authority without the express written consent of PreCheck Health Services, Inc., Secured Party, or its assigns shall constitute a default of the finance agreement for which this payment is being made. We also understand that if we have supplied a copy of a check, bank statements or any other form of bank verification, then PreCheck Health Services, Inc., Secured Party, or its assigns shall withdraw funds from the account number and routing number listed on the check, bank statements or any other form of bank verification. An electronic version of this document with signature shall be considered an original.