One Time Permission & Recurring ACH Payment Authorization
Company Name & Authorized Administrator Info
Company Name
*
Authorized Banking Administrator Full Name
*
Authorized Administrator Email
*
example@example.com
Authorized Administrator Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Bank Name and Account Deteails
Bank Name (US Banks Only)
*
Routing Number
*
Re-enter Routing Number
*
Bank Account Number
*
Re-enter Bank Account Number
*
Billing Frequency
I Agree To Allow Interactive Limited to Process Payment by ACH:
*
When Invoice Payment is Approved By Sending Interactive Limited An Email
Automatically Monthly Three Days After Invoice Is Received
One Time Only For Invoice Noted in Space Below
Notes and Comments
Authorization
By signing below I, the company administrator entered above, authorize charges to my company’s checking account. If agreeing to monthly billing my company will be sent an invoice three days prior to the ACH transaction. Transactions will be withdrawn from our bank unless I or another company representative disputes the charges shown on the invoice. Undisputed charges will appear on your bank statement as an “ACH Debit” from Haverford Road Interactive LLC / DBA Interactive Limited LLC,These payments to Interactive Limited are for services like ad campaign management, website building, and maintenance.I understand that this authorization will remain in effect until I or another representative of my company cancels this ACH permission by sending an email to dave@interactivelimited.com and then receives a confirmation email in return.I further certify that I am an authorized administrator of this bank account.
Signature
*
Continue
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