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

Bank Contact Name

First NameLast Name

Phone

Please enter a valid phone number.Format: (000) 000-0000.

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

ACH Authorization Form

General Information

ACH Authorization Form