please include copy of voided check on page 2 *** 1
5203 Gateway Drive Grand Forks, ND 58203 1-855-434-2486
One Time ACH Payment Authorization Form Sign and complete this form to authorize 2ND AMENDMENT WHOLESALE INC. to make a one time debit to your checking or savings account. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Please complete the information below & include copy of voided check on page 2: I ____________________________ authorize 2ND AMENDMENT WHOLESALE INC. to charge my bank account (full name) indicated below for _____________ on or after ___________________. (amount)
(date)
Billing Address ____________________________ City, State, Zip ____________________________
Account Type:
☐ Checking
Name on Acct
_______________________________
Bank Name
_______________________________
Phone# ________________________ Email
________________________
☐ Savings
Account Number _______________________________
Bank Routing #
_______________________________
Bank City/State
_______________________________
*** PLEASE INCLUDE COPY OF VOIDED CHECK ON PAGE 2 ***
SIGNATURE: ____________________________________
DATE: ________________
I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of the payment being rejected for Non Sufficient Funds (NSF) I understand that 2ND AMENDMENT WHOLESALE INC. may at its discretion attempt to process the charge again within 30 days, and I agree to an additional $30 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute 2ND AMENDMENT WHOLESALE INC.’s billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.
1
COPY OF VOIDED CHECK 2ND AMENDMENT WHOLESALE INC. requires that you also provide a copy or scan of a voided check for the account that you wish to pay with ACH from. Our team uses this voided check for an additional verification step before we process the ACH transaction. The best way to provide a voided check is to write “VOID” on the check, tape it to the area indicated below, then scan the page to your computer. Alternatively, you can submit the voided check as separate scanned image attached to the same email as this completed form. If you do not have access to a scanner you may mail this completed form with copy of voided check to our address or fax it to 1-855-808-9697. IMPORTANT: Please make sure that below voided check matches bank routing number & account number information that was provided on page 1.
PLEASE SUBMIT THIS COMPLETED FORM USING ANY OF THE AVAILABLE OPTIONS BELOW: Email: [email protected] Fax: 1-855-808-9697 Paper Mail: Our mailing address is 5203 Gateway Drive, Grand Forks, ND 58203
2
One Time ACH Payment Authorization Form Sign and complete this form to authorize 2ND AMENDMENT WHOLESALE INC. to make a one time debit to your checking or savings account. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Please complete the information below & include copy of voided check on page 2: I ____________________________ authorize 2ND AMENDMENT WHOLESALE INC. to charge my bank account (full name) indicated below for _____________ on or after ___________________. (amount)
(date)
Billing Address ____________________________ City, State, Zip ____________________________
Account Type:
☐ Checking
Name on Acct
_______________________________
Bank Name
_______________________________
Phone# ________________________ Email
________________________
☐ Savings
Account Number _______________________________
Bank Routing #
_______________________________
Bank City/State
_______________________________
*** PLEASE INCLUDE COPY OF VOIDED CHECK ON PAGE 2 ***
SIGNATURE: ____________________________________
DATE: ________________
I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of the payment being rejected for Non Sufficient Funds (NSF) I understand that 2ND AMENDMENT WHOLESALE INC. may at its discretion attempt to process the charge again within 30 days, and I agree to an additional $30 charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute 2ND AMENDMENT WHOLESALE INC.’s billing with my bank so long as the transaction corresponds to the terms indicated in this agreement.
1
COPY OF VOIDED CHECK 2ND AMENDMENT WHOLESALE INC. requires that you also provide a copy or scan of a voided check for the account that you wish to pay with ACH from. Our team uses this voided check for an additional verification step before we process the ACH transaction. The best way to provide a voided check is to write “VOID” on the check, tape it to the area indicated below, then scan the page to your computer. Alternatively, you can submit the voided check as separate scanned image attached to the same email as this completed form. If you do not have access to a scanner you may mail this completed form with copy of voided check to our address or fax it to 1-855-808-9697. IMPORTANT: Please make sure that below voided check matches bank routing number & account number information that was provided on page 1.
PLEASE SUBMIT THIS COMPLETED FORM USING ANY OF THE AVAILABLE OPTIONS BELOW: Email: [email protected] Fax: 1-855-808-9697 Paper Mail: Our mailing address is 5203 Gateway Drive, Grand Forks, ND 58203
2
