Payment Authorization Form

Payment Authorization Form

All information contained herein shall remain confidential.
Customer Details
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Business Name*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Payment
How would you like to pay?
Banking Details
Bank Name*
Name on Account*
Account Type*
Routing Number*
Account Number*
Authorization Terms for ACH Payments:

I/We authorize Earthly Gourmet Distribution LLC (Earthly Gourmet) to initiate debit entries from my/our account at the Depository (identified below) for the purpose of order/transactional payments, or initiate credit entries to my/our account for the purpose of refunds or credits.

I understand that it is my/our responsibility to immediately inform Earthly Gourmet of any change of information to our account and/or the financial institution listed below. Otherwise,

I/we agree to pay any bank service charges as a result of any unsuccessful attempts to retrieve funds due to invalid account and/or
information.
- Payments will be charged within a 1–2-week period following each completed delivery.
- To mitigate additional administrative time and costs, should we experience a delay due to a decline/bounce back charge in credit card and/or ACH transaction processing, payment terms will revert to COD at the discretion of Accounts Receivable; whereby payment will be expected in the form
  of cash, check, or Paypal with a 3% processing fee at the time of delivery.
- Beginning July 1st, 2024, there will be a $25 fee for credit cards or ACH that are declined.
Signature*

Clear
Should be Empty:

Payment Authorization Form

Customer Details

Preferred Method of Payment

Banking Details