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 me (or either of us) of its termination in such time and in such manner as to affect COMPANY and DEPOSITORY a reasonable opportunity to act on it. The undersigned Debtor agrees to be bound by the NACHA Operation Rules, as amended and in effect from time to time.

Depository Financial Institution

Depository Bank Name

Depository Branch

Branch Address

City, State and Zipcode

Account Details

ABA / Routing Number

Account Number

Recurring Payment?

Transfer Autorization

I (we) hereby authorize NETSIRV, LLC, hereinafter called “COMPANY” to initiate debit entries to my (our) checking or savings account indicate below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) 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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EIN