The undersigned hereby authorizes Dar-Liens, Inc. to act as my/our Limited Agent in preparation and service of Health Care Provider Liens and Releases, to protect my/our Lien entitlements under the laws of the State of Arizona. (ARS 33-931-ET SEQ).

We the undersigned agree that Dar-Liens, Inc. will prepare Liens and Releases and bill me/us. (Please check one.)

(1)
If I/we choose to be billed on a daily basis, payments are due by the last day of the month billed. I/we agree to have payments into Dar-Liens, Inc. office no later than the last day of each month. If payment is not in by the last day of each month there will be a two percent (2%) late fee assessed to my/our account at the beginning of the next month.

(2)
If I/we choose to be billed on a monthly basis, payments are due in full by the fifteenth (15th) day following the date on the monthly invoice. If payment is not received by Dar-Liens, Inc. by the fifteenth (15th) day of the following month, there will be a monthly late fee of two percent (2%) assessed to the account.

Any balance that exceeds 60 days will be put on C.O.D. status until my/our account is paid in full. We agree to pay all fees incurred to collect my/our delinquent account, the cost of which will be added to my/our account balance. This is an exclusive contract for a period of one year renewable each year on the anniversary date of the first signing of the contract.

This contract forbids me/us from using Dar-Liens, Inc. "Intellectual Property" which is protected by Federal Statutes against copyright and trademark infringements. I/we also agree not to compete with Dar-Liens, Inc. in any regard to the preparation of Health Care Provider Liens or Releases for the purpose of filing my/our own Liens and/or Releases by me/us or anyone under my/our employ.

PLEASE COMPLETE THIS PORTION IN THE NAME(S) YOU ARE KNOWN BY THE STATE OF ARIZONA

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