One-Time Payment by eCheck Please choose your date here*I authorize NetEffect, LLC to initiate either an electronic debit or to create and process a demand draft against my bank account on or after MM slash DD slash YYYY Please add amount in dollar here*for the amount of I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law. My account information is as follows:*I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law. My account information is as follows: Invoice Number Quote Number Enter the Invoice Number* Enter the Quote Number* Bank InformationBank ABA Routing Number:* Bank Account Number:* Bank Account Type:*Business CheckingCheckingSavings* By entering my printed name and date below, I am accepting this as my digital signature and authorization to proceed as described above. I also stipulate that I have all necessary authorization from the company from which the debit or draft will be drawn. Company Name* Printed name:* Date Signed:* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ Share this:TwitterFacebookLike this:Like Loading...
