2017-18 Western Oregon Mental Health Alliance (WOMHA) Quarterly Payment Plan Agreement for One Time Initiation Fee

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Please complete each section to participate in paying WOMHA dues on a quarterly basis. An additional $10 will be charged each quarter.

This agreement written between, listed member below and WOMHA, 2601 25th Ste. SE, Ste 420 Salem, Oregon 97302 is to set up a payment plan equal to the total amount due of $1,000.00 to pay for WOMHA one time Initiation Fee. This amount will be paid off in quarterly installments of $260. The first installment is due by 12/31/2015 with the remaining installments due by March 31, 2018, June 30, 2018, & September 30, 2018. Membership is further contingent upon meeting the requirements of WOMHA & AMHA NW

TYPE FULL NAME *

TYPE OF CREDIT CARD *

Mastercard

Visa

NAME AS IT APPEARS ON THE CREDIT CARD *

CREDIT CARD ACCOUNT NUMBER *

CREDIT CARD EXPIRATION DATE *

CREDIT CARD BILLING ADDRESS *

Street or PO Box

CITY *

STATE *

ZIP CODE *

I agree to allow WOMHA to withdraw funds from my credit card for Initiation fees. *

Please place initials below acknowledging payment amount (US Dollars): $260.00 on December 31, 2018

I agree to allow WOMHA to withdraw funds from my credit card for Initiation fees. *

Please place initials below acknowledging payment amount (US Dollars): $260.00 on March 31, 2018

I agree to allow WOMHA to withdraw funds from my credit card for Initiation fees. *

Please place initials below acknowledging payment amount (US Dollars): $260.00 on June 30, 2018

I agree to allow WOMHA to withdraw funds from my credit card for Initiation fees. *

Please place initials below acknowledging payment amount (US Dollars): $260.00 on September 30, 2018

Signature of WOMHA Member or Prospective Member *

Write name in text box

PLEASE ENTER DATE OF SIGNING *

YYYY

Time

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