Common Contracts
1 similar Authorization Agreement for Automatic Payments contracts
ContractAuthorization Agreement for Automatic Payments • January 13th, 2010
AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS ***ACH DEBITS/CREDITS*** Trans/ABA Number: Checking/Savings Account Number: Customer Name on Account: Address: City: State: Zip Code: Financial Institution: IMPORTANT: PLEASE ATTACH A VOIDED CHECK OR SAVINGS DEPOSIT SLIP WITH THIS FORM TO ENSURE ACCURATE PROCESSING. I hereby authorized Totah Communications, hereinafter called "COMPANY", to initiate debit entries, if necessary, credit and adjustment entries in error to my checking or savings account (select one) and the depository named above, hereinafter called "DEPOSITORY", to debit and/or credit the same to my account. There will be a $3.00 processing fee for all customers that are not setup on a recurring monthly basis and have this form on file. ***CREDIT CARD CHARGES / CREDITS*** Payment Method: VISA American Express Mastercard Discover Card Security Code (three or four digits) Credit Card Number: Expiration Date: Name on Credit Card: Address: City: State: Zip Code:
