ACH Authorization – Netsirv Production Site

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH)

Company Name

Your Name

EIN Number

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.

Depository Financial Institution

Depository Bank Name

Branch

City

State

Zip Code

Bank routing number ABA

Account Number

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.

Date

Please sign that you agree

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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.