I acknowledge that I am only eligible for self defense coverage benefits by obtaining
a Gold or Platinum Membership with the Self Defense Association. Upon membership
approval the Gold and Platinum Members will be listed as an additional insured on
a policy owned by the Self Defense Association, Inc., and will be mailed a certificate.
I acknowledge that I am eligible for these benefits because I currently hold a valid
Carry Concealed Weapons Permit issued by my state of residence or I am in the process
of obtaining a permit. I also acknowledge that the benefits applied for herein will
become null and void and no longer in effect immediately upon the expiration, suspension,
cancellation, voluntary relinquishment, any other termination, or the state declines
to issue me the Carry Concealed Weapons Permit identified above or applied for.
SDA reserves the right to modify the benefits at will with 45 day notice to the
members. I declare that the above statements and representations are true and correct
and that no facts have been suppressed or misstated. I acknowledge the completion
of this application does not bind Self Defense Association to accept my application
for membership. Any subsequent membership issued will be in full reliance of the
statements and representations made in this application and any materials submitted
with this application will be made part of the membership issued.
I request and authorize Self Defense Association, (SDA) Inc. to make monthly withdrawals via electronic transfer from my credit card account above, in the amount indicated above. The name that you will see on your credit card statement will be, “Self Defense Association, (SDA)”. This agreement begins during the month and year here stated above for the Self Defense Association, (SDA) Membership application registered to the individual named above. I request that this Authorization, unless previously revoked, continue to apply to any changes later made in products or services provided. I understand that Self Defense Association, (SDA) Inc. reserves the right to withdraw previous month(s) due during the month in which the first transaction is processed. Debits to my account will occur between the 1st and 10th of the month. I agree that the term of the Self Defense Association, (SDA) Membership agreement is for 12 months from the beginning date stated above. This pre-authorized payment agreement will automatically renew annually and will remain in effect until cancelled in writing by either party. I understand that refunds and cancellations are prorated and I will not receive a refund if the amount of the refund is less than $1.00. I agree to notify the Self Defense Association, (SDA) in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this web form. As a convenience to me, I hereby request the credit card issuer above to accept and honor transfer withdrawals from my account. I agree that your rights in respect to each transfer shall be the same as if it were drawn personally by me and that you shall be fully protected in honoring such transfer. I further agree that if any such withdrawal is dishonored, whether with or without cause and whether intentionally or inadvertently, the credit card issuer shall be under no liability whatsoever if such dishonor results in the forfeiture of benefits. These Authorizations shall remain in effect until revoked in writing, mailed to the parties at the address of record. The Company or Financial Institution shall have a reasonable time to act on the revocation notice. I understand that my membership and benefits in the Self Defense Association, (SDA) will be cancelled upon termination of authorization or failure of payment of the above card. I have retained a copy of these Authorizations. Please send all correspondence to, Self Defense Association (SDA), Inc., P.O. Box 9320, Mission, KS 66201, 913-396-5640