A/E Graphics Inc ACH Payment Authorization

Check One Below and Enter Your Details:*

ACH on File – You authorize charges to your ACH account. You will be charged for open invoices. The charge will appear on your Bank Statement. You agree that no prior-notification will be provided. I authorize A/E Graphics, Inc. to charge my ACH account below for open invoices.One (1) Time Charge – You authorize a one-time charge to your account listed below. By signing this form, you give us permission to debit your account for the amount indicated below. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account. I authorize A/E Graphics, Inc. to charge my ACH account indicated below.

Enter total amount to pay and invoice/sales order number(s):Invoice Amount* Invoice(s) / Sales Order Number(s) *

Company / Individual Name*

Company / Individual Name

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

ACH Account Information*

Business CheckingBusiness SavingsPersonal CheckingPersonal Savings

Account Holder's Name Company / Individual Name *
Routing Number Routing Number *
Account Number Account Number *

Applicant agrees that the information provided is accurate and complete. Applicant also acknowledges that all orders may be terminated immediately at A/E Graphics discretion if any charges are declined or charged backs are claimed against any outstanding invoiced amount. Disputes to amounts invoiced should immediately be reported to billing@aegraphics.com

Changes to the status of this account can be emailed to billing@aegraphics.com

Signature*

Date/Time

I authorize the above named business to charge the ACH account indicated in this authorization form according to the terms outlined above. I certify that I am an authorized user of this ACH account and that I will not dispute the payment with my bank; so long as the transaction corresponds to the terms indicated in this form.