Provider Account Setup

I certify that I am an authorized representative of the Company named above and that I possess the authority to execute this Agreement. Company acknowledges that this authorization shall remain in effect until it is formally revoked in writing and agrees to provide Genova Biologix with written notice at least 15 days prior to any changes in its account information or the termination of this authorization. Company understands that, due to the nature of electronic transactions, funds may be withdrawn from its account immediately upon authorization of an individual transaction. Company further acknowledges that it will have a limited timeframe to report and dispute any errors. Additionally, Company agrees to specify the correct form of payment when placing purchase orders. In the event an ACH transaction is rejected for any reason, Genova Biologix may, at its discretion, attempt to reprocess the payment within 24 hours or utilize an alternative payment method on file. Company agrees to pay an additional charge of $35.00 for each returned check, with such charge processed as a separate transaction from the originally authorized payment. Genova Biologix may also require a credit card on file as an alternative payment method in the event that checks are returned for any reason. Company certifies that the provided bank account is configured for ACH transactions and agrees to reimburse Genova Biologix for any penalties and fees incurred as a result of the transaction. Company further acknowledges that the initiation of ACH transactions to its account must comply with the provisions of U.S. law.

I certify that I am either the cardholder or an authorized user of the credit card listed above and possess the authority to enter into this Agreement on behalf of the Company. Company acknowledges that this authorization will remain in effect until it is formally revoked in writing and agrees to notify Genova Biologix in writing at least 15 days prior to any changes to its account information or the termination of this authorization. In the event that a credit card transaction is rejected for any reason, Company understands that Genova Biologix may, at its discretion, attempt to reprocess the credit card or, alternatively, process the payment using another payment method on file. It is the responsibility of the undersigned to ensure with the financial institution that sufficient funds are available for the payment. The Company further agrees to accurately specify the correct form of payment when submitting purchase orders. Company acknowledges and agrees that Genova Biologix shall not be liable for any delays in shipment arising from payment rejections by Company's financial institution. I authorize Genova Biologix to charge the credit card listed above, provided that each transaction is initiated according to the terms of this agreement. For your convenience, your card will be kept on file for future orders.