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ACH Authorization Form

The document contains authorization forms for credit card and ACH transactions for Premier Business Solutions. Clients provide their payment information and agree to terms regarding payment processing and notifications. The authorization remains effective until canceled in writing, and clients acknowledge their responsibility for any NSF charges.

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Frances Athena Baraoidan
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© © All Rights Reserved
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86 views1 page

ACH Authorization Form

The document contains authorization forms for credit card and ACH transactions for Premier Business Solutions. Clients provide their payment information and agree to terms regarding payment processing and notifications. The authorization remains effective until canceled in writing, and clients acknowledge their responsibility for any NSF charges.

Uploaded by

Frances Athena Baraoidan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Credit Card Authorization

Client Name: _________________________________________________________


Name on Card: ___________________________________ Visa Mastercard American Express Discover
Card Number: ___________________________________ Expiration Date: _____ /______ CVV Code: __________
Address: _________________________________________ City: ___________________ State: ________________________ Zip: __________
I authorize Premier Business Solutions to charge my credit card in the amount of $_________________ and other
such amounts as outlined in the agreed Engagement Letter.

Signature: ________________________________________ Date: __________________________

ACH Authorization
Financial Institution: _____________________________________________________________
Account Number: _________________________________ Routing Number: __________________________________
I authorize Premier Business Solutions to charge my bank account in the amount of $ __________________ and other
such amounts as outlined in the agreed Engagement Letter.

Signature: ______________________________________ Date: ___________________________

Terms
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify
Premier Business Solutions in writing of any changes in my account information or termination of this
authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend
or holiday. I understand that the payments kay be executed on the next business day. In the case of an ACH
Transaction being rejected for Non-Sufficient Funds (NSF). I understand that Premier Business Solutions may
at its discretion attempt to process the charge again within 30 days, and agree to an additional charge for
each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring
payment. I acknowledge that the origination of Ach transactions to my account must comply with the
provisions of U.S. law. I certify that I am an authorized user of this credit card and/or bank account and will
not dispute these scheduled transactions with my bank or credit card company; so long as the transactions
correspond to the terms indicated in this authorization form.

1403 Greenbrier Parkway, Ste 220,


Chesapeake, VA 23320

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