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Payment Enrollment Form

To be used at time of sign up by the broker to review fees and sign agent up for recurring credit card payments.

Payment	Amount	Month	Total	Initials
Associate Fee (monthly)	$145	Monthly	$145
Sign Up Fee (one time)	$100	One time	$100

Billing Information (exactly as it appears on your credit card statement)

Name on Card: [esiggravity formid="1" field_id="54" display="value" ]

Card type : [esiggravity formid="1" field_id="56" display="value" ]

Card Number: [esiggravity formid="1" field_id="57" display="value" ]

Exp: [esiggravity formid="1" field_id="58" display="value" ]

CVC: [esiggravity formid="1" field_id="59" display="value" ]

Billing Address:

[esiggravity formid="1" field_id="52" display="value" ]

I hereby authorize Realty ONE Group Sterling to initiate the above credit card charge and to charge me recurring monthly fee payments as set forth herein and/or late fees (if applicable). I further authorize Realty ONE Group Sterling to charge the above card for fees associated with promotional materials ordered at my direction that the company incurred on my behalf, including but not limited to signs and rider and business cards. A new authorization must be completed if I change my account, close my account, or change financial institutions. The authorization remains in effect until cancelled in writing or upon termination.

By signing, I agree to the terms stated above.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Signed by Kevin Story
Signed On: May 4, 2020

Timestamp

Audit

May 29, 2019 8:47 am CDT

Payment Enrollment Form Uploaded by Kevin Story - kstory@rogsterling.com IP 98.172.136.208