I hereby understand and agree that:
My full name is firstName lastName.
Email Address: email
I am authorizing payment(s) toward Simmons & Clark Jewelers File Number fileNumber.
Social Security Number (SSN): XXX-XX-altFileNumber
I have the authority to make payments from the following account:
Card Number: creditCardNo
Billing zip code: billingZip
Card Security Code: csc2
Routing Number: routingNo
Account Number: accountNo
I understand that Simmons & Clark Jewelers will deduct $amount from this account on effectiveDate.
I further understand that, unless I call Simmons & Clark Jewelers at (313) 963-2284 to cancel, a payment of $amount will be deducted from this account frequency starting from effectiveDate.
These payments will continue for a total of totalPayments payments.totalPayments
Electronic Signature:
Type your full name in the box to electronically sign this document.
Please contact Simmons & Clark Jewelers with any questions, to cancel a payment arrangement or request a refund.
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