ACH Authorization – Net – Netsirv Production Site

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH)

Your Name

Company Name

EIN / SS ID

This authorization is to remain in full force and effect until COMPANY has received written notification from either party of its termination. The Signer below agrees to be bound by the NACHA Operation Rules, as amended and in effect from time to time.

Bank Account Details

Bank Name

Branch Name

Branch Address

City, State, Zip

Signer Account Details

ABA / Bank Routing Number

Account Number

Account Type

Recurring Payment?

Transfer Authorization

I hereby authorize NETSIRV, LLC, to initiate debit entries and/or repositories to the account indicate. I acknowledge that the origination of ACH transactions to my account must comply with provisions of US law.

Signiture

NOTE: All written debit authorizations must provide that the debtor may revoke the authorization only by notifying in the originator in the manner specified in the Authorization.

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