ACH Authorization

Company Name: *

I (We) hereby authorize Company as shown above, hereinafter called COMPANY, to initiate debit entries to my (our) bank account as detailed below, and to debit the same to such account. Should a transaction be returned, I (we) further authorize debiting this account for non-sufficient fund fees according to applicable State Law. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law.

Bank Name: *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Full Name on Account: *

Account #: *

Routing #: *

SWIFT Code#: *

Account Type: *CheckingSavings

Account Class: *Consumer AccountBusiness Account

Debit Payment Amount: *

Frequency of Payments: *

Signature *

Date: *

Customer Printed Name: *

Customer Title: *

Customer Contact Phone #: *