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Agent Billing Form
AGENT INFORMATION
Name:_______________________________________________________
(as it appears on the credit card)
Credit Card #: _______________________________________ Expiration Date: ________________
Card Type:
Card Code: ___________
Billing Address: ____________________________________________________________________
_________________________________________________________________________________
Office Location:
Smyrna
Sumner County
All agents with PARKS receive a monthly agent bill for their charges. Monthly charges include agent
services fees, advertising, etc. All agent bills are due by the fifth (5th) of each month following the
receipt of your agent bill.
We do accept credit/debit cards and are happy to arrange to have your agent bill automatically charged
to your credit/debit card each month.
If you do not wish to have your agent bills charged to your credit card, please provide a check for deposit
on your account for $200.
If you choose to pay your agent bill by check each month, you can mail it to the Corporate Office in
Brentwood or ask the Office Manager to send your check via courier.
To be completed by the agent, returned to the Office Manager and forwarded to the corporate office.
Date:_________________