Customer Form

Customer Credit Preference

Please complete this form to confirm your preferred method of payment for credits issued by RTI. Your information will be securely stored and accessible only to authorized personnel. All data provided will remain confidential and will be used exclusively for internal business purposes.
Payment Method*

Hold to account – Credit will be held and applied against future customer remittancesCheck Payment – Full credit amount will be paid by check (not applied to open balances)ACH Payment – Full credit amount will be paid via ACH (not applied to open balances)
- Payable to
- Remittance Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- ACH Authorization Form
- Account Holder Name
- Bank Name
- Bank Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Bank ABA/Routing Number
- Bank Account Number
- Bank Account Type
  
  CheckingSavings
- Bank Contact Name
  
  First NameLast Name
- Phone
  Please enter a valid phone number.
- This agreement is between   Enter Company Name*   "Customer" and Reclamation
  Technologies USA, "Company". "Customer" authorizes "Company" to initiate credit entires to bank account noted above. In the event of an erroneous transaction, "Customer" authorizes the reversal or correction of erroneous transaction. "Customer" may change its designation of bank or bank account information by written notice to "Company". Notice must be received by "Company" at least 7 days before the effective date of the change or termination.
  
  This agreement is effective as of   Date
  Authorized Representative Name:   First Name   Last Name
  
  Signature:   Signature   Date:   Date

Payment Terms
Preferred Payment Terms:*

Due on ReceiptNet 15 - Credit Reference RequiredNet 30 - Credit Reference Required
- Credit Reference 1
- Company Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.
- Contact Person
  
  First NameLast Name
- Title
- Email
  example@example.com
- How long have you held this account?
- Credit Reference 2
- Company Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.
- Contact Person
  
  First NameLast Name
- Title
- Email
  example@example.com
- How long have you held this account?
- Credit Reference 3
- Company Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.
- Contact Name
  
  First NameLast Name
- Title
- Email
  example@example.com
- How long have you held this account?

AUTHORIZATION FOR RELEASE OF INFORMATION:
I hereby warrant that the above information is true and correct, and is furnished for the purpose of establishing a customer relationship with Reclamation Technologies USA, LLC. I hereby agree that Reclamation Technologies USA, LLC may investigate my record and that, if approved, Reclamation Technologies USA, LLC may furnish this authorization to secure the information they need to establish a business relationship.
Name*

First NameLast Name
Title*
Signature*
Date*

MonthDayYear
Date
Should be Empty:

New Customer Form

General Information

Customer Credit Preference

ACH Authorization Form

Payment Terms

AUTHORIZATION FOR RELEASE OF INFORMATION: