DASH Payment Card Transaction Release Ver 020821

inPrepaid Technologies Transaction & Information Release

I authorize NeuBridg, Inc. (“NeuBridg”) to obtain any and all transaction history f rom inPre- Paid Technologies for all transactions shown on the payment card issued to me. I further authorize NeuBridg, Inc. to email the report received f rom inPre-Paid Technologies to me at the email address below. If no email is provided, NeuBridg may mail the report to the address on file of my payment card.

I hold NeuBridg, Midwest Group Benefits, inPre-Paid Technologies harmless and shall defend them against any and all claims
Click in the upper right hand corner to switch the from from EN to SP
Employer
Full Name
Last 4 Social Security Number
Date of Birth

MonthDayYear
Date
Phone
Is this a cell phone? Yes or No
Email
example@example.com
If you do not have an email, please leave the Email field blank or empty.
ALL FIELDS ARE REQUIRED
Employee Signature

Clear
Date

MonthDayYear
Date
© 2023 NeuBridg, Inc. All Rights Reserved Payment Card Transaction Release Ver 020821.1
Should be Empty:

Click in the upper right hand corner to switch the from from EN to SP