Automatic Bill Pay Authorization

ACH Payment Authorization
I hereby authorize Frontline Source Group, Inc. ("FSG") to electronically debit ("ACH") my bank account according to the terms outlined below. I acknowledge that electronic debits against my account must comply with United States law.
Customer Information
Company Name:*
Authorized Signer Name:*
Authorized Signer Name
Address:*
Primary Phone*
E-mail*

Customer Bank Account Information
Type of Account:*

CheckingSavings
Type of Account:*

BusinessConsumer
Name of Bank*
Bank Name*
FSG Invoice #:*
Additional FSG Invoices
Amount of $*
Total $ Amount of All Invoices
Routing Number:*
Re-Enter Routing Number:*
Account Number*
Re-Enter Account Number*

Terms and Conditions
Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature, or any resulting agreement between you and Frontline Source Group, Inc. You are also confirming that you are authorized to enter into this Agreement.

In case the transaction is returned for ANY REASON you understand that Frontline Source Group, Inc. may at its discretion attempt to process the charge again within 5 days, and you agree to an additional $50.00 charge for each ACH returned for ANY REASON, which will be initiated as a separate transaction from the authorized payment. You have certified that the
above business bank account is enabled for ACH transactions, and agree to reimburse Frontline Source Group, Inc. for all penalties and fees incurred as a result of your Company bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions at a charge of $50.00 for each ACH returned from your bank for ANY REASON. Both parties agree to be bound by NACHA Operating Rules as they pertain to these transactions. Company acknowledges that the origination of ACH transactions to its account must comply with the provisions of U.S. law. Company agree not to dispute the scheduled transaction with your bank provided the transactions correspond to the terms indicated on this authorization form.
I Accept*

By checking this box and typing my name below, I agree to the terms and conditions of the Electronic Signature Agreement, and I am Electronically Signing and Authorizing payment by ACH to Frontline Source Group, Inc. for the amount listed.
First Name*
Middle Initial
Last Name*
Date*

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ACH Payment Authorization