Payment Agreement / Electronic Signature
By typing my name below, I am authorizing Emergency Care Programs to charge my account (be it checking, debit or credit card) in the amount of $0.00. I certify that I am the authorized account holder and acknowledge that this is a one-time charge. I also understand this is a binding agreement and non-refundable and in the case of credit cards, no refunds of this transaction may be made through a chargeback process.
In the event that my payment is return unpaid for any reason, I agree that I will be fully responsible for any and all charges associated with such occurrences. I acknowledge that submitting this form constitutes my agreement to all conditions set by ECP. I verify that all the above information is accurate and truthful.