Recurring Payment Authorization Form

To: Sinha Capoeira, Inc., hereinafter “Sinha”

I hereby give authority to Sinha to draw monthly drafts against my account for payment of my monthly membership.

I understand that this authorization will remain in effect and my payments will be recurring each month drawn on the 1st of each month15th of each month until this authorization is terminated by me at any time by emailing a notice to sinhacapoeira@hotmail.com.

Further I agree that upon a stop/pause membership notice, Sinha will stop my recurring payments within thirty (30) business days. This will be a permanent stop on this preauthorized payment. I may however, establish a new recurring payment authorization in the future.

I understand that should a debit to my checking account be rejected because of insufficient funds, a fee will be assessed in the amount of $20.00.

I understand that my cancelling of monthly payments also cancels my membership overall in Sinha and I cannot attend classes unless authorized by Sinha.

I further understand there will be no refunds or credits for unattended classes. It is my responsibility to attend classes.

Please complete the information below:

I authorize Sinha Capoeira, Inc., to debit the bank account indicated below on the 1st of each month15th of each month of each month for payment of my monthly membership in the amount of

Your Name *

Name of Student*

Your Email*

Price Quoted*

Day for Recurring Payment*
1st of each month15th of each month

Name on Account*

Bank Name*

Bank Account Number*

Bank Routing#*

Bank City/State**

Signature*

Date Sign*