300 - ACH Form - Ice-Employee

300 – ACH Authorization

RECURRING ACH PAYMENT AUTHORIZATION

You authorize regularly scheduled charges to your account. You will be charged the total amount due from the invoices received from Santiam Ice Company for deliveries from your checking account for each billing period. A receipt for each payment will be provided to you, and the charge will appear on your banking statement. You agree that no prior notification will be provided.

Business Name

Store/Location Name

Contact Name

Contact Phone #

Email *

Name(s) on Bank Account *

Account Number *

Routing Number *

Bank Name *

Bank Branch *

Bank Phone Number *

Type of Bank Account *

Picture of a Blank Check

Maximum file size: 516MB

Name

First

Last

Title

Date *

I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify the Merchant in writing of any changes in my account information or termination of this authorization at least fifteen (15) days before the next billing date. If the above-noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this account and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.

Signature *

Clear