U.S. Member Services Order + ACH Payment Authorization Form

U.S. Member Services Order + ACH Payment Authorization Form

FORM IS ENCRYPTED
IPI Member #
We can look it up for you later, if it's not handy!
Alternate Verification for IPI Membership Number:

Street Address

Street Address Line 2

Business Location CityBusiness Location State

Postal / Zip Code
Company*
Your Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Which online ordering platforms are used in your business?*

Photo FinaledakisPixFizzN/AOther

ACH Banking Information
Type of account*

Business CheckingBusiness SavingsPersonal CheckingPersonal Savings
Name on Checking Account*
example Million Dollar Photo dba Million $ Pic
Routing Number*
Must be 9 digits
Account Number*

Terms + Conditions
Upon approval of ACH, we will automatically draft for the amount indicated and your total charges will appear on your monthly bank statement.

I authorize Independent Photo Imagers (IPI) to debit my account as identified above according to the terms stated here. This authorization shall remain in effect until IPI receives written notification from me of any intent to terminate this payment plan and at such time and in such manner as to afford IPI reasonable opportunity to act (minimum of 30 days).

I authorize this plan to continue as long as the payment amount remains unchanged or until the plan is terminated by me. All other changes such as service adjustments, frequency modification, and bank account or credit card numbers, will require a new Electronic Payment Authorization Form to be filled out and submitted via https://form.jotform.com/vrennie/us-member-order-ACH-form at least 15 days prior to any change being implemented. I will inform IPI of any bank account or credit card changes that occur during my participation in this program.

I acknowledge and agree that IPI has the right to modify any and all recurring fees with at least 30 days prior written notice to me via the email address I have provided.

I understand that this payment plan may be canceled by IPI, due to Non-Sufficient Funds (NSF). I understand that I will be liable to pay the NSF fees that will be charged by my bank. In the event that IPI is charged an NSF fee by the bank or a revoke authorization fee, I understand that I will be liable to pay these fees and authorize IPI to debit my account for these amounts.

I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this electronic payment plan. I indemnify and hold IPI, the bank, and IPI Merchant Services provider, harmless from damage, loss, or claim resulting from all authorized actions hereunder.

The IPI MSP and all components thereof including but not limited to any and all Managed Marketing Services are copyrighted and licensed for the exclusive use of active IPI members who are subscribers to the IPI MSP. Any other use of the IPI MSP is strictly prohibited and doing so violates both copyright and licensing rights held by Independent Photo Imagers, Inc.
Signature*
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U.S. Member Services Order + ACH Payment Authorization Form

Membership, Subscriptions, Licenses + Setup Fees

ACH Banking Information

Terms + Conditions